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Treated like criminals 

Dispensing error guidance fails to remove jail threat page 4 

Your guide to the three stages of childbirth page 19 

Cashing in on the latest category M prices page 28 


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Film Coated Tablets 

Fexofenadine Hydrochloride 

Fexofenadine Hydrochloride 
Telfasl 120mg film-coated (ablets 

The tablets are film-coated peach coloured tablets containing 120 rug 
fexofenadine hydrochloride, equivalent to 1 1 2 mq ol fexofenadine. 

For relief oi symptoms associated wild seasonal allergic rhinilis. 
Dosage & Administration: 

For Ihe Irealment ol seasonal allergic rhinilis in adults and children aged 
12 years and over, the recommended dose ol fexofenadine hydrochloride 
is 120 mg once daily belore a meal. The efficacy and safety of fexofenadine 
hydrochloride has not been established in children under 6 years ol age. 


Known hypersensitivity to any of the producl's ingredients. 

Studies in adults have shown thai il is nol necessary to adjust Ihe dose ol 
lexolenadine hydrochloride in Ihe elderly or in renally or hepalically 
impaired patients. However, lexolenadine should be administered wilh 
care in these special groups. 

Side effects (Please refer lo the Summary of Product 
Characteristics for full side-effect details): 

In controlled clinical trials Ihe incidence of commonly reported adverse 
events observed wilh lexolenadine was similar lo that obseived with 
placebo. These adverse events were headache, drowsiness, nausea, 
dizziness, and sleep disorders or paroniria. such as nightmares. In rare 

30 Tablets 



cases rash, hypersensitivity reaclions wilh manifestalions such as 
angioedema, chest lightness, dyspnoea, and systemic anaphylaxis have 
also been reported. 
Pregnancy & Lactation: 

Fexofenadine is nol recommended in pregnancy or lor mothers breast- 
feeding their babies, due lo absence ol experience in this group ol patients. 
Legal Category: POM 

Marketing Authorisation Number: PL 04425/0157 
NHS Price: Pack of 30 Tablets: £6.23 
Further information is available Irom Winthrop Pharmaceuticals, 
One Onslow Slreel, Guildford. Surrey, GUI 4YS. 

Date of Revision of Prescribing Information: April 2009 



Economise without compromi! 

Adverse events should be reported and information about adverse event reporting can be found on 
Adverse events should also be reported to Winthrop Pharmaceutical UK Ltd as follows:- Email: Tel. 01483 554242 Fax.:01483 55480(1 

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The arrival of the CPS dispensing 
error guidance was meant to be a 
red letter day for pharmacists. Sadly 
the deal delivered this week seems 
to be more of a red herring (p4). 

We had hoped this guidance 
would go some way to shielding 
pharmacists from prosecution while 
the Medicines Act was overhauled. 
The sad truth is it doesn't. Instead 
what we've got is largely a rehash of 
the CPS's existing position. 

Most of the guidance is a revision 
guide to medicines law. In fact it's 
not until the penultimate page that 
you hit upon something noteworthy 
- the key considerations for 
prosecutors bringing dispensing error 
cases. Prosecutors are urged to 
assess factors including the 
seriousness of an error and 
whether it was reported straight 
away before pursuing a case. 

The six-point guide could form an 
invaluable best practice guide for 
pharmacists and it is worth 
considering when reviewing your 
SOPs. But this is a small ray of light 
in an otherwise underwhelming 
document for pharmacy. 

It seems hard to reconcile this 
guidance with what was first 
pledged at an all-party pharmacy 
group meeting last summer. There 
we were told of an interim deal that 
would offer real protection for 
pharmacists. Prosecutors would face 
sterner tests before they could bring 
criminal charges, the meeting heard. 
Hopes ran high of achieving an 
effective stop-gap until longer term 
legislative changes were secured. 

Those hopes appear to have been 
slowly extinguished in the 
subsequent 12 months of 
negotiations with the CPS. 

Perhaps that's no surprise. The 
CPS can call on a wealth of legal 
expertise. Its vastly experienced 
lawyers are likely to have made 
formidable adversaries for those 
arguing the pharmacists' corner. 

It adds to a feeling that 
throughout this process pharmacy 
has been outmanoeuvred. Only a 
matter of weeks ago CPS told the 
Elizabeth Lee appeal hearing that it 
couldn't commit on a publication 
date for errors guidance. This 
scuppered efforts to nullify both 
parts of the Medicines Act that make 
dispensing errors a criminal offence 
during the hearing. You are left to 
ponder what might have been had 
the judges known how quickly 
guidance would actually arrive 

But despite these frustrations all is 
not lost in the battle to decriminalise 
errors. The pharmacy minister has 
gone on record with his intention to 
secure legislative changes to protect 
pharmacists. In Earl Howe, at last, 
pharmacy appears to have a minister 
prepared to proactively champion 
the sector he represents. However, 
even with his support it's unlikely the 
threat of criminal prosecution can be 
lifted until changes to the Medicines 
Act in 2012. With two pharmacists 
prosecuted by the CPS under the act 
since 2007, another two years will 
come too late for some. 

Max Cosney, News Editor 


Dispensing errors: criminal threat stays 


Update: Pregnancy part 4 


Contractors underpaid by NHS 


Practical Approach: osteoporosis 


HIV meds adherence scheme launches 


Glucosamine: evidence explained 


Conscience clause on probation 


What the Budget means for you 


CIP payment chaos 


Ethical Dilemma: methadone supply 


Product and market news 


Category M Barometer 


Xrayser and David Reissner 


Health & wellbeing: create a happy team 




Careers: benefits of joining your LPC 



© UBM Medica, Chemist + Druggist incorporating Retail Chemist. Pharmacy Update and Beauty Counter Published Saturdays by UBM Medica, Ludgate House. 245 Blackfnars Road. London SE1 9UY C + D online at Subscriptions With C + D Monthly pricelist £250 (UK), without pncelist £205 (UK) ROW price £365 Circulation and subscription UBM Information Ltd. Tower House. Sovereign Park. Lathkill St, 
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Criminal threat stays as CPS fails 
to deliver on dispensing errors 

Disappointing guidance for prosecutors has 'changed nothing', say legal experts 

Chris Chapman 

The long-awaited guidance on the 
prosecution of dispensing errors 
released this week has fallen short of 
expectation and "changed nothing", 
legal experts have warned. 

The Crown Prosecution Service 
(CPS) guidance on prosecutions 
under the Medicines Act, first 
promised last June, had been hoped 
to shield pharmacists from criminal 
prosecution until a full review of the 
Act could be completed. 

But Charles Russell solicitor David 
Reissner warned the guidance was 
self-justifying and did not lift the 
threat of conviction. 

"There is a lot of self-justification 
here... and when you get to what 
ought to be the meat, actually there 
is nothing there... it isn't even a 
restatement of their position, it's a 
reminder of things [prosecutors] 
should be taking into account 
anyway," he said. 

"My view is the CPS was hoping to 
stall, but has come under political 
pressure and the CPS has aimed to 
fob off the politicians [with 
guidance]," Mr Reissner added. 

Hilary D'Cruz, partner at Ansons 
Solicitors, agreed the guidance was 
unlikely to protect pharmacists who 
make a dispensing error from 

Support for pharmacists is required, not punitive measures, says Earl Howe 

criminal prosecution. 

"The guidance does not create any 
legally enforceable rights or override 
the current law. It may assist with 
clarity, but the fact remains human 
dispensing errors can be penalised 
unless the limited defences apply," 
Ms D'Cruz warned. 

However, the pharmacists could 
use the guidance to update SOPs in 
line with prosecution criteria, 
allowing them to minimise their risk, 
she added. 

Pharmacy minister Earl Howe said 
the DH was exploring legislative 
options to protect pharmacists 
from prosecution, such as the review 

of the Medicines Act, "as a matter 
of priority". 

"We firmly believe a legislative 
framework for dispensing is needed 
that will support a learning culture 
as opposed to a punitive one," he said. 

More than 12,000 pharmacists 
signed a petition calling for the 
decriminalisation of dispensing 
errors following the conviction of 
Elizabeth Lee, whose sentence in 
2009 for a single dispensing error 
was overturned last month at the 
Court of Appeal. 

See next week's C+D for an 
analysis of the CPS guidance. 

Industry view 

"The guidance is a step in the 
right direction, but what we are 
pressing for is a change in the 
law. And the Department of 
Health is listening." 
Jeremy Holmes, chief 
executive and registrar, RSPGB 

"The CPS guidance is a welcome 
step forward to safeguard the 
public interest, and to achieve a 
consistent approach to 
prosecutions. We still await a 
change to the law so that the 
correct balance is embedded for 
the long term." 
Nanette Kerr, director 
of pharmacy, NPA 

"Although there is strong 
opposition to the current law, 
the guidance could be used by 
pharmacists as a useful tool in 
the interim. Pharmacists should 
familiarise themselves with the 
guidance... so they can 
demonstrate they have taken all 
reasonable steps to minimise 
the risk of dispensing errors." 
Hilary D'Cruz, partner, 
Ansons Solicitors 

Automated dispensing machine 
hits the UK for trial this autumn 

PharmaTrust hopes its machines will be 
allowed into community pharmacies 

An automated pharmacy dispensing 
machine will be trialled in UK 
hospitals this autumn, with its 
owners targeting rollout into 
community pharmacies by late 2011. 

PharmaTrust said the Department 
of Health-backed pilots could 
support changes to supervision laws 
that will allow the technology to be 
used in the community sector. 

Peter Ellis, PharmaTrust executive 
director, told C+D: "We are 
deploying the machines in hospitals, 
but the intention is to get enough 
data to inform the DH of safety. We 
then hope the government will give 
us the necessary changes to allow us 

entry into community pharmacy." 

The Medcentre machine features 
a live video link to a pharmacist who 
oversees dispensing. 

Each machine can stock up to 
2,000 medicines and is set to cost 
around £50,000. 

The technology was not an 
attempt to replace pharmacists with 
robots, PharmaTrust stressed. 

Instead the technology could free 
up pharmacists to concentrate on 
delivering patient services, the 
manufacturer claimed. 

Existing rules require a responsible 
pharmacist to be in charge of every 

However, the Health Act 2006 
gives the secretary of state powers 
to enable changes that could lead to 
one pharmacist being responsible for 
multiple premises. 

This concept of remote 
supervision has come under fire from j 
pharmacy representatives. 

The PDA launched a campaign to 
stop remote supervision with 
candidates successfully elected to 
the national boards of the new 
professional leadership body. 

The hospital pilots of the 
Medcentre will be assessed on 
patient and pharmacist satisfaction 
as well as impact on error rates. MC 

4 Chemist +Druggist 26.06.10 

Sign up to C+D's daily news alerts 


Sector demands further 
transparency on pay 

Calls follow NHS underpayments of up to £37,000 for one contractor 

Zoe Smeaton 

Industry leaders have demanded 
more transparency in NHS pharmacy 
payments after businesses revealed 
shortfalls of up to £37,000 each in 
the last two years 

The calls came as PSNC reminded 
contractors the deadline for 
requesting that their payments up to 
the end of March 2009 be checked 
was June 30. 

Payment problems have been 
occurring since pharmacy's 
paymaster, the NHS Business 
Services Authority (NHS BSA), 
introduced its automated CIP 
payment system. 

One contractor told C+D they had 
lost more than £37,000 in total due 
to underpayments. Others reported 
losses of up to £8,000 and multiples 
expressed concern at the situation. 
Boots, Lloydspharmacy and Asda all 
said they had experienced difficulties 
with payments and would back 
more transparency in payments. 

Umesh Modi, a specialist 
pharmacy financial adviser at 
accounting firm Silver Levene said 
pharmacists had seen "erratic" 
payments since the introduction of 
CIP and warned this could threaten 
the survival of some businesses. He 

NHS prescription payment accuracy 

Accuracy aimed for by 

Underpayment for one 
independent contractor 

Compensation for contractors 
for hassle caused by the system 

Days spent checking scripts by 
one contractor each month 

Deadline to request checks 
up to March 2009 

called for more transparency and 
said pharmacists should be able to 
see how payments were calculated. 

One contractor agreed: "There 
is no way to check exactly how 
we're paid and no transparency. I've 
been grossly underpaid and the 
system should be so transparent 
that we should be able to check 
every script." 

Fingers were pointed at NHS BSA 
for the administrative burden and 
problems caused by the system, but 
others urged greater action from 
pharmacy bodies. Another 
contractor said: "I phoned PSNC 

and they said I should call NHS BSA, 
but they're the people representing 
us so they should have made an 
effort to take up my case." 

The DH said it was working with 
NHS BSA and PSNC to introduce 
more transparency into payments. 
And NHS BSA said new sorting 
arrangements introduced in April 
would help to resolve some of the 
accuracy problems. 

CIP payment chaos 

See news analysis plO 

Boots to pilot nurse-led clinics 

Boots is set to pilot nurse-led health 
clinics in its stores but has reassured 
pharmacists it is still committed to 
developing their roles within the 

In July the multiple will launch 
clinics in Nottingham and Milton 
Keynes, offering private services 
including health checks, lifestyle 
advice and sexual health services. 
The clinics will be run by nurses 
and offer both appointments and 
walk-in services. 

Tricia Kennerley, director of 
healthcare public affairs, told C+D 
patients and staff had backed the 
initiative and that the nurses offered 
an extra resource that could help 
with time pressures in pharmacies. 
The clinics would also signpost 
patients to the pharmacies where 

appropriate, she added. 

"We do want to continue to 
develop our pharmacists' skills in 
delivering services and become 
much more service providers as 
opposed to just dispensing 
prescriptions. I think that's where 
we really create the value, in giving 
patients better healthcare services," 
Ms Kennerley said. 

She added that Boots was keen to 
find ways to deliver NHS- 
commissioned services from the 
clinics and added: "Early 
conversations have been very 
positive with the NHS but we are 
moving into new territory and these 
things take time." 

Ms Kennerley said Boots now had 
CPs or other NHS providers offering 
services from 17 stores and planned 
to roll out such schemes more 
widely. ZS 

"Business avoided the worst of the 
chancellor's 'unavoidable' budget" 

Find out how George Osborne's deficit 
reduction measures will affect you. See page 25 

PDA slams Boots pension 

The PDA has voiced criticism 
of changes to the Alliance Boots 
pension scheme. PDA chief John 
Murphy said the union felt the 
Protection of Employment 
legislation was not being used 
as it had been intended, in a 
letter to Boots executive 
chairman. Boots declined to 
comment on the letter. 

England flag ban 

The UK's biggest multiples have 
blacklisted England flags from 
pharmacies during the World 
Cup. Both Lloydspharmacy and 
Boots said flying the flag was 
"inappropriate" for pharmacy 

NHS operations change 

The NHS Operating Framework 
has been revised to slash 
management costs and abolish 
targets to focus on outcomes. 
Overall management costs will 
be reduced by £850 million by 
2013-14, health secretary Andrew 
Lansley said. 

New insulin guidance 

The National Patient Safety 
Agency (NPSA) has issued 
guidance to reduce the number of 
wrong doses of insulin. The 
guidance recommends 'units' is 
never abbreviated, and all clinical 
areas treating patients using 
insulin have an adequate supply of 
syringes and needles. 

Topical NSAIDs effective 

Topical NSAIDs are more effective 
than placebo in treating short- 
term pain, a Cochrane review has 
found. The review of 31 studies 
found topical treatments were 
safe and effective painkillers 
with only minor side effects in 
some patients. 

No tool of choice for CV 

Nice has removed its 
recommendation for measuring 
cardiovascular risk using methods 
based on the Framingham 
equation. The change means both 
the Framingham equation and the 
QRISK score can now be used in 
England and Wales. 

26.06.10 Chemist+Druggist 5 


More news online 

HIV adherence 
project launches 

Patient support with 'no blame' approach 

Co-op's h lyfever bM 

Co-op Pharmacies in Bristol are 
leading a hayfever treatment and 
advice service. Nine stores will 
offer the service, part of Bristol 
PCT's minor ailment scheme. 

£12bn saving programme 

NHS officials could deliver 
£12 billion in savings over the next 
year without making rash 
decisions, cancelling operations or 
axing doctors, according to the 
think-tank 2020health.The 
organisation recommended 
patients being advised to buy 
OTC medicines instead of relying 
on prescriptions as one cash- 
saving alternative. 

Frontline services fear 

A Patients Association survey has 
revealed rising concerns about 
cuts to frontline NHS services. 
The survey showed a 60 per cent 
increase in the number of 
respondents choosing cuts to 
frontline services when asked 
what concerned them most about 
the health service. 

Nice targets food trade 

Tens of thousands of lives would 
be saved from heart disease and 
stroke if manufacturers produced 
healthier food, according to Nice 
guidance published this week. It 
calls for the food industry to 
reduce the salt and saturated fats 
in the food it produces further. 

■ .■■■--.! - 5 piw !?.' "J*- 

Sales of pharmacy businesses are 
picking up, according to pharmacy 
finance company Pharmacy 
Partners, which said it has seen a 
"record start" to 2010, with clients 
with strong businesses looking to 
acquire new pharmacies. 

Supply chain crystal ball 

Pharmacists have been asked by 
the NPA to give their opinions on 
what a medicines supply chain 
model of the future should look 
like. An event will be held in 
Edinburgh on June 30 and aims to 
draw up alternatives to DTP and 
reduced wholesaler supply deals. 

Chris Chapman 

Researchers at the London School of 
Pharmacy have launched a £2 
million programme to improve 
adherence to antiretroviral therapy 
(ART) for HIV. 

The five-year programme, funded 
by the National Institute for Health 
Research, follows research at the 
school, which found more than one 
third of patients had low adherence 
to ART within six months of starting 

The pharmacist-led research 
team would take a "no blame" 
approach to non-adherence, 
approaching the problem from the 
perspective of the patient and 
tailoring support to patients on 
an individual basis, said lead 
researcher Rob Home. 

Pay mothers to quit smoking. It 
may seem counter-intuitive in an 
NHS scrambling to save every 
penny, but this radical step was 
precisely what was under the 
microscope last week at the UK 
National Smoking Cessation 
Conference (UKSCC) in Glasgow. 
It's an idea that has interesting 
ramifications for pharmacy. 

First, the evidence. Incentive 
schemes are nothing new, and 
their track record in smoking 
cessation is disappointing. Two 
Cochrane reviews, both updated in 
2008, show no evidence of 
increased long-term quit rates, 
although both suggest incentives 

"Health practitioners have a duty 
to facilitate informed choice about 
ART and to support optimal 
adherence in the long term. This 
research programme will provide an 
evidence base to help clinicians do 
this," professor Home added. 

Previous research from the school 
has shown patients' non-adherence 
is often seen by patients as logical, 
for example because of a lack of 
symptoms, concern about adverse 
events, and fear of toxicity or 

Although the project is focused 
on HIV, researchers hope that 
the results could be used to 
improve medicines adherence in 
other long-term conditions, 
including asthma, inflammatory 
bowel disease, bipolar disorder, 
chronic kidney disease, renal 
transplant and epilepsy. 

do attract people to join schemes. 

But pregnant smokers are, it 
seems, an exception. Yet another 

2008 Cochrane review, focusing on 
psychosocial interventions to stop 
smoking in pregnancy, looked at 
72 controlled trials involving more 
than 25,000 mums. It found 
incentives were the most effective 
intervention, helping around 24 per 
cent of women to quit. 

There's also evidence of how 
incentives work in pharmacy. In 
2007,Tayside launched its 'Give it up 
for baby' scheme, in which pregnant 
mothers registered with a pharmacy 
smoking cessation scheme. Over a 
period of up to 12 months they were 
rewarded with a weekly £12.50 Asda 
voucher. By the end of the first year, 
1 40 mothers across the Tayside 
region had stopped smoking, costing 
around £1,700 per quitter. 

All of which leaves a muddied 
picture, but one that fits with what 
we know. A report on smoking 
cessation services in Scotland for 

2009 found pharmacies typically 
had higher sign-up but lower quit 

DH to review 
white paper 

The Department of Health is 
set to review the pharmacy 
white paper to ensure the 
commitments within it fit with 
the new government's plans, 
C+D understands. 

The comments came after 
industry leaders warned the new 
coalition government was yet to 
back the blueprint, which had 
been the policy of the previous 

A DH spokesperson confirmed: 
"In the coming months, we will 
review the commitments in the 
pharmacy white paper against 
health priorities we have 
identified to ensure these meet 
our vision for patient-centred 
services, focused on prevention 
as much as treatment and 
ensuring good health outcomes." 

Both the Conservatives and 
Liberal Democrats backed the 
principles of the white paper in 
pre-election interviews with C+D. 

The pharmacy white paper was 
published in April 2008. ZS 

rates than other services. This is, 
it seems, for two reasons. First, 
pharmacies don't report back very 
well, and so are probably doing 
more than they let on. Second, 
pharmacy services are less 
intensive than dedicated stop 
smoking services, and so have 
lower success rates. 

But it's swings and roundabouts 
-the higher recruitment may 
mean actual numbers of quitters 
are equivalent, or higher, through 
pharmacies. And we know 
incentives increase uptake. For 
pregnant smokers at least, the 
benefits to both mother and child 
means that offering cessation 
incentives is worth considering. 

To discuss this subject in 
private with your pharmacy 
colleagues, join the debate in 
C+D's Linkedln group at - search for 
Chemist and Druggist. 

Chat with Chris on Twitter: 

Clinical debate C+D's Chris Chapman looks at the evidence behind the headlines 

Paying pregnant smokers to quit 


Druggist 26.06.10 

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C+D Award 2010: over 400 photos and videos 


Could pharmacy 
compete with universal 
CP dispensing? 

"I don't think so because if there was 
CP dispensing then there would be 
no reason to send a patient to a 
pharmacy as they go to their CPs 

Patricia Ojo, Day Lewis, 
Bromley, Kent 

"I think that is a resounding no as all 
of the funding from prescriptions, 
and therefore services, would dry up 
It would also affect the patients as 
medicines are not dispensed by 
doctors, they are dispensed by 

Keith Howell, Delmergate 
Pharmacy, Beltinge, Kent 

en ve 



Armchair view: The prospect of 
dispensing GPs has received a 
definite no from pharmacists who 
don't believe the industry could 
compete with doctors offering 
prescription dispensing at their 

Next we sk's question: 
CPS error guidelines are finally here 
- so what's your verdict on the 
promised protection from 
prosecution for dispensing mistakes? 
Vote at 

Conscience clause put 
on probation by GPhC 

New regulator to prioritise full review after fresh criticism by patients 

Max Cosney 

The conscience clause will face an 
official review after fresh criticism 
from patients of powers that allow 
pharmacists to refuse services on 
religious grounds. 

The General Pharmaceutical 
Council (GPhC) vowed a full 
investigation within a year of its 
launch this autumn. 

The pledge came after the clause 
dominated responses to a second 
GPhC consultation on pharmacy 
standards published last week. 

Most of the 86 respondents 
criticised the GPhC decision to 
include powers that allow 
pharmacists to pull out of services 
such as EHC. 

Pharmacists should be made to 
put aside personal beliefs in the 
patient interests, according to critics 
- largely comprising representatives 
of the public. 

However, the GPhC said feedback 
from a broader range of patients and 
pharmacists was needed before 
making a final decision. 

Duncan Rudkin, GPhC chief 
executive, told C+D: "It's clearly an 

Duncan Rudkin: extra guidance aims to 
defuse tension over use of the clause 

unusual issue and one that's 
polarised opinion. We need to get to 
the bottom of that and whether 
we've misunderstood it." 

He added: "If there's a 
comprehensive chasm between 
profession and public, and I'm not 
saying there is, that's not a situation 
we'd find ideal and we'd want to find 
a way of reconciling that." 

The GPhC's review will target 
views on all the pharmacy standards 
agreed by its council last week and 

PCT taken to court 
over services payment 

A Hertfordshire pharmacist is taking 
legal action against his PCT in a 
dispute over pay. 

Graham Phillips, owner of 
Hertfordshire-based Manor 
Pharmacy (Wheathampstead), 
claimed the trust had not paid him 
£1,200 owed for the electronic 
prescription service and £120 for 
smoking cessation services. 

A spokesperson said: "NHS 
Hertfordshire can confirm that it is 
involved in legal proceedings and as 
such cannot comment further on 
any details." 

Mr Phillips told C+D he had sent 
off the required paperwork several 
times but it was not acknowledged 
by the PCT. He received a response 
saying they would not pay him for 
the services he had performed as 

they had received the forms late, 
Mr Phillips claimed. 

Mr Phillips maintains he 
submitted them on time and has 
started proceedings through the 
small claims court against the trust. 

He said: "It's not about the 
money, it is the principle. They are 
months and months late paying for 
things, but when the boot is on the 
other foot there is no discretion." 

No date has been set for the case 
to be heard, Mr Phillips said. HF 

How the latest category 
M prices will affect 
your business 

Data and analysis on p28 

not centre exclusively on the 
conscience clause, Mr Rudkin said. 

The review will include focus 
groups, workshops and seminars 
with patients and pharmacists. 

Informal views will also be 
encouraged through letters 
and emails. 

The conscience clause was 
subject to intense media criticism 
earlier this year when a pharmacist 
was vilified in national newspapers 
for refusing to dispense the 
contraceptive pill. 

Mr Rudkin backed extended 
guidance from the GPhC around 
using the clause to help defuse 
tension. This will include case 
studies and practical scenarios 
to help pharmacists. The new 
regulator has also recommended 
the display of notices telling 
patients of services that could 
be refused in its standards code. 

Read all the views on 
the conscience clause 
and other standards at 

iPhone app 
for pharmacy 

NHS Bristol has 
launched an 

application that 
allows patients 
to find their 

The free tool, 
which cost 
under £2,000 to develop, features 
details of every health service in 
Bristol including its GPS location. 

Emily Wighton, a pharmacist at 
Old School Pharmacy in Bristol, said: 
"I think this is a great initiative - 
keeping up with the times and 
making sure that healthcare 
providers are accessible." 

But S Meghji of S A Meghji 
Pharmacy in Bristol, said: "Everyone 
knows where their pharmacies are 
and you can ring NHS Direct." HF 

8 Chemist+Druggisi 26.06.10 



training courses 

Supporting pharmacy success 

^ Enhancing 

[ patient care 

Pfizer commitment 
to pharmacy 

As part of a healthy partnership" 1 our commitment is to 
listen to you, the community healthcare experts. We want 
to understand the professional issues facing community 
pharmacy so that when we act to develop support and 
training, it meets your professional development needs, 
helping you and your pharmacy succeed. 

Our MUR workshops have proved successful and we are 
continuing to develop further "soft skills" training to help 
you counsel patients, implement pharmacy services and to 
help grow your pharmacy. 

For the most up-to-date details on our "soft skills" 
meetings please visit 
(insert code R948 on first page). 

Listening to pharmacy 

a healthy 

HP 0358. Date of preparation: May 2010- 


For all the latest wholesaler news 

Making your 
payment request 

Profits slipping through sector's 
fingers: the CIP payment chaos 

As the June 30 
deadline for checking 
prescription payments 
approaches, Zoe 
Smeaton speaks to 
the underpaid and 
asks why the sector 
can't be remunerated 

Contractors have seen up to £37,000 go missing from their prescription payments 


While experts say there is a 
trend towards underpaymenl 
remember that some 
contractors may have been 
overpaid by NHS BSA. It's alsi 
worth remembering that NH 
BSA will check another mont 
at random as well as any you 


You can request the check by 
email until June 30 by filling 

Prescription pricing problems 
continue to be "a significant 
concern", according to England's 
pharmacy contract negotiator. And 
with stories of businesses missing 
out on up to £37,000 still coming to 
light, there is little evidence to ease 
the fears. 

Since the automated CIP pricing 
system was brought in by the 
sector's paymaster, the NHS 
Business Services Authority (NHS 
BSA), problems such as prescription 
switching have led to many 
contractors being paid incorrectly. 

One independent contractor told 
C+D that after initial checks showed 
in some months he had been 
underpaid by £2,000, he asked NHS 
BSA to check all his payments over 
the previous 18 months. He was 
eventually repaid more than 
£37,000. Similar checks by Imran Jan 
of Churchfield Pharmacy in south 
Woodford led to him being credited 
around £8,000 in total, while Jayesh 
Lakhani of Elgon Chemist in Enfield 
received over £6,000. 

Mr Lakhani had been prompted to 
check payments when he found he 
was short on cash and he found for 
some specials he was being paid for 
only one ingredient, not the whole 

In the latest twist to the tale, 
contractors have been given until 
June 30 to request checks on their 
CIP payments up until the end of 
March 2009. The move follows steps 
to try to improve payment accuracy 
by the NHS BSA, and a £1,000 

compensation payment to businesses 
to cover the additional workload 
caused by problems with the system. 

In April this year pharmacists were 
given revised sorting guidelines, 
having to separate high value scripts 
from others, in an attempt to 
improve accuracy. They will also be 
able to see details of payments on all 
items over £100. While welcome, it 
is unclear whether these measures 
will be enough. Early feedback 
already suggests some pharmacists 

"Why should 
contractors foot 
the admin bill for 
a system that has 
proved unfit for 

are not sorting their scripts correctly 
and as a result may not have their 
expensive items double checked. 

And the DH and NHS BSA still 
refuse to comment on why 
contractors should have to foot the 
administrative bill when millions of 
pounds have been spent on a system 
which has proven unfit for purpose. 

Faisal Tuddy, commercial manager 
on the pharmacy team at Asda, is 
critical. He says with better testing 
some of the CIP problems could 
have been avoided, and adds: "NHS 
BSA has not made it easy to 

challenge where we believe there 
has been an issue. This is 
compounded by the arbitrary nature 
of their counter checks." 

Denise Hebron, a customer 
services manager at NHS BSA, says 
simply: "We have realised that there 
were some issues but those have 
been corrected, and we are giving 
pharmacists the opportunity to get 
their accounts checked." 

She adds that improvements are 
still being made, saying: "I'm not 
going to say it will be 100 per cent 
correct because nobody in the world 
is 100 per cent correct but I think it's 
going to hit our target of 99.8 per 
cent accuracy [for the total 

An apology is all very well, but 
contractors now have little 
confidence in the system, so what 
can we do moving forwards? 

Obviously the key step is for 
contractors who believe they have 
been underpaid to request checks 
(see Making your payment request 
box). But they will need to be 
vigilant about payments in order to 
spot problems. As Mr Lakhani says, 
his business relies only on NHS 
income so the problem was easy to 
spot, but there will be pharmacists 
"who aren't solely reliant on the 
NHS and who are suffering but 
aren't able to pinpoint where that is 
coming from". 

A longer term solution could be to 
improve transparency. As Umesh 
Modi, specialist pharmacy adviser at 
Silver Levene, says: "It seems to me 


the form available at 



Contractors asking for checks 
have to give a valid reason for 
doing so and this needs to give 
enough detail as there have 
been reports of NHS BSA 
ref using requests until more 
information is supplied. 


Contractors have complained 
that NHS BSA has not made the 
checking process easy. Imran Jan 
of Churchfield Pharmacy in 
south Woodford told C+D: "I had 
to be very persistent and patient 
with them and keep requesting 
the checks. It has been quite a 
long process, to put it mildly." 

that in this day and age of 
technology surely the NHS could tell 
pharmacists how their payments are 
calculated so the pharmacist could 
check them." 

On the positive side, the DH is 
working with PSNC and the NHS 
BSA to identify ways to increase the 
transparency of payments. But the 
sector must hope they succeed 
because if they don't, there could be 
casualties. As Mr Modi warns: 
"Pharmacists need to be sure of 
what monies are coming in and 
going out to remain in business. 
With erratic payments it becomes 
impossible and threatens their very 
livelihood and survival." 

10 Chemist Druggist 26.06.10 

now you can swap some cigarettes with 
nicorette® inhalator as a safer option to smoking 


NICORETTE® Inhalator is first to market with 
a new indication for those unwilling or unable 
to quit smoking. By replacing some cigarettes 
with NICORETTE® Inhalator you'll be providing 
a safer option when they aren't yet ready to 
break free from cigarettes. 

For every cigarette, there's a nicorette 1 

As soon as they are ready, smokers should aim to stop smoking completely 

Nicorette Inhalator Product Information: 
Presentation: Inhalation cartridge containing 10mg nicotine for 
oromucosal use via a mouthpiece. Uses: Relieves and/or prevents 
craving and nicotine withdrawal symptoms associated with 
tobacco dependence. It is indicated to aid smokers wishing to quit 
or reduce prior to quitting, to assist smokers who are unwilling or 
unable to smoke, and as a safer alternative to smoking for smokers 
and those around them. It is indicated in pregnant and lactating 
women making a quit attempt Dosage: Adults and Children over 
12 years of age: Nicorette Inhalator should be used whenever the 
urge to smoke is felt or to prevent cravings in situations where 
these are likely to occur. Smokers willing or able to stop smoking 
immediately should initially replace all their cigarettes with the 
Inhalator and as soon as they are able, reduce the number of 

cartridges used until they have stopped completely. Smokers 
aiming to reduce cigarettes should use the Inhalator, as needed, 
between smoking episodes to prolong smoke-free intervals and 
with the intention to reduce smoking as much as possible. As soon as 
they are ready smokers should aim to quit smoking completely. When 
making a quit attempt behavioural therapy, advice and support 
will normally improve the success rate. Those who have quit 
smoking, but are having difficulty discontinuing their Inhalator 
are recommended to contact their pharmacist or doctor 
for advice. Contraindications: Children under 12 years and 
Hypersensitivity. Precautions: Unstable cardiovascular disease, 
diabetes mellitus, G.I disease, uncontrolled hyperthyroidism, 
phaeochromocytoma, hepatic or renal impairment, chronic throat 
disease, obstructive lung disease or bronchospastic disease Stopping 

smoking may alter the metabolism of certain drugs. Transferred 
dependence is rare and both less harmful and easier to break than 
smoking dependence. May enhance the haemodynamic effects of, 
and pain response to, adenosine Keep out of reach and sight of 
children and dispose of with care. Best used at room temperature. 
Pregnancy & lactation: Only after consulting a healthcare 
professional. Side effects: Cough, irritation of throat and mouth, 
headache, nasal congestion, nausea, vomiting, hiccups, 
palpitations, Gl discomfort, dizziness, reversible atrial fibrillation. 
See SPC for further details. RRP (ex VAT): 6-Starter pack £6.99, 
42-Refill pack £21.99. Legal category: GSL. PL holder: McNeil 
Products Ltd, Roxborough Way, Maidenhead, Berkshire, SL6 3UG. 
PL number: 15513/0179 Date of preparation: March 2010 
Date of preparation: May 201 05761 


Ratiopharm UK launches mouth 
ulcer and cold sore patches 

Ratiopharm UK has 
announced the 
launch of 
Mouth Ulcer 
Patch and 
Dissolving Cold 
Sore Patch. 

Both products 
come in the 
form of a 
dissolvable film 
patch that can be 
used to cover and 
treat the affected area. 

Algopain-Eze Dissolvable Mouth 

Ulcer Patch sticks to 
mouth ulcers on 
application and acts as a 
barrier between the ulcer 
and bacteria, which 
prevents infection, 
according to the company. 
Dissolving Cold Sore 
Patch sticks to cold sores 
after it is made wet and 
delivers zinc sulphate 
directly onto the sore, 
says Ratiopharm UK. 

£8.25 (Algopain-Eze 
Dissolvable Mouth Ulcer Patch); 
£8.99 (Algopain-Eze Dissolving 
Cold Sore Patch) 


Debit card cost 
Accepting payment by debit card 
costs a retailer four times more 
than cash, the British Retail 
Consortium (BRC) has 
demonstrated. The BRC's annual 
Cost of Collection Survey 
includes results from more than 
seven billion transactions in 
21,500 shops of all types. The 
new government should 
intervene to cut the excessive 
charges banks levy on retailers 
for accepting credit and debit 
cards, says the BRC. 

Wimbledon travel sweet 

Simpkins has announced the 
launch of a Strawberry & Cream 
travel sweet for the start of 
Wimbledon. The travel sweets 
come in a tin and are perfect for 
anyone wanting to enter into the 
spirit of the tournament, 
according to the company. 
Price: £1.35 

New appetite suppressor 

Capsiplex has announced the 
launch of Capsiplex Appetite 
Suppressor. Clinical trials have 
shown one capsule will stop 
cravings and reduce portion 
sizes by 50 per cent, the 
company says. 
Tel: 0845 279 7207 

Arimidex results 

AstraZeneca has announced the 
results of a 10-year trial into the 
benefits of breast cancer 
treatment Arimidex. The results 
demonstrate the benefits of 
Arimidex continue up to five 
years after treatment completion, 
according to the company. 

Goldshield supply update 

Goldshield Pharmaceuticals has 
given updates on when four of its 
products are expected to be back 
in stock. Fentazin 2mg tablets are 
expected to be available in the UK 
in mid-July, Diamox SR 250mg 
capsules in early July, Stelazine 
1mg/5ml Syrup and Stelazine 5mg 
tablets at the end of June, and 
Eltroxin 25microgram tablets mid- 
July, the company has announced. 
Goldshield Pharmaceuticals 
Tel: 0208 588 9273 

12 Chemist Druggist 26.06.10 

Ratiopharm UK head of OTC Robert 
Hall (pictured, right) explains the 
retail opportunities for Algopain-Eze 
Dissolving Cold Sore Patch. 

How big is the cold sore 

Over one in five people suffers from 
cold sores in the UK and 80 per cent 
carry the virus that causes them. 
Once people have the virus it does 
not go away. The cold sore market is 
worth £27.8 million,* but there is 
room for growth. 

What is available on the 
market already? 

Since the launch of aciclovir as a P 
medicine, creams have dominated 
the market and recently patches 
have been launched. However, some 

sufferers have experienced problems 
with adhesive patches sticking to the 
sore, which is painful. 

Who can pharmacists 
target Algopain-Eze at? 

This product uses an innovative 

Market focus 

• The mouth ulcer market is 
worth £23.6 million a year (IRI, 
52 weeks to Nov 28, 2009). 

• 50 per cent of people with 
mouth ulcers do not treat 

• Mouth ulcers recur in 20 per 
cent of sufferers. 

Pip codes: 354-3410; 354-3402 
Ratiopharm UK 
Tel: 02392 386330 

technology that allows the patch to 
stick to your lip without adhesive. 
Customers who have had problems 
with patches in the past, because 
they are unsightly or painful, will like 
this product as it is soothing and you 
can put make-up over it. Some 
customers may also have problems 
with creams that have to be used at 
the first sign of a tingle or they don't 
work. These patches can be put on at 
any time. 

What kind of profits can 
pharmacists expect? 

Independent pharmacies supplied 
via AAH and Phoenix can sell the 
product at an introductory launch 
price of £7.99, which will give them 
a 45 per cent profit boost initially. 

* IRI, 52 weeks to Nov 28, 2009 

GSK 'revitalises' denture market 
with Poligrip cleansing products 

GSK Consumer Healthcare has announced 
the launch of two denture cleansing 
products from Poligrip. 

Poligrip Total Care Denture Cleansing 
Tablets are antibacterial, which helps to 
reduce plaque-induced irritation, according 
to the company. 

Poligrip 3 Min Ultra Denture Cleansing 
Tablets deep cleans in three minutes, 
which makes it ideal for day or night 
cleaning, GSK says. 

The company says it plans to revitalise 

the "dormant" denture category with 
the launch of these two cleansing 

Prices: £1.29/33 

Pip codes: 355-3849 (Poligrip 3 Min 

Ultra Denture Cleansing Tablets); 

355-3831 (Poligrip Total Care Denture 

Cleansing Tablets) 

GSK Consumer Healthcare 

Tel: 0845 762 6637 



first to marke 
unwilling o 


In the UK approximately 10 million adults smoke cigarettes; 1 50% of 
smokers are not happy with their current smoking habit, of these 1 2% are 
planning to stop abruptly and 35% are either planning to reduce the amount 
of cigarettes they smoke or reduce the amount they smoke with a view to 
stopping altogether/' However, with no help or support the power of nicotine 
addiction means that few will actually succeed. Research has shown that 
only 3% of smokers will succeed in an unaided quit attempt in any 12-month 
period. 1 

Pharmacists are among the most accessible of all healthcare professionals. Everyday 
almost two million people in the UK visit a community pharmacy for health advice" 
making pharmacists ideally placed to provide support to those who are thinking 
of stopping smoking. Nicotine Replacement Therapy (NRT), along with advice and 
support, is an effective and simple way to help smokers reach their ultimate goal of 

The Inhalator is a unique format of NRT which acts as a cigarette replacement 
to help control cravings, with up to one in three smokers remaining abstinent at 
12-weeks. 5 ' 6 ' 7,8 It is made up of a mouthpiece through which the user draws in nicotine 
by active inhalation. Held like a cigarette, it occupies the hand as well as mimicking 
the hand-to-mouth action. 

As well as controlling cravings, Nicorette' Inhalator has been shown to relieve nicotine 
withdrawal symptoms associated with tobacco dependence ', and is indicated: 

To aid smokers wishing to quit 

To aid smokers to reduce the amount of cigarettes they smoke prior to quitting 
To assist smokers who are unwilling or unable to quit smoking by replacing some 
cigarettes with Nicorette* Inhalator for a safer option to smoking 

The extension of the indication to encompass those unwilling or unable to quit 
smoking means you can provide Nicorette Inhalator as a safer 
option to smoking when smokers are not yet ready to break 
free from cigarettes. Data suggests that for smokers unable or 
not interested in giving up abruptly, a softer and more gradual 
approach should be considered. Such an approach may produce 
more people wanting to quit. 10 In fact, one in three of those who 
halve their smoking with Nicorette" Inhalator or gum have been 
shown to quit in one year." 


1 . ASH Facts at a Glance - Smoking Statistics; 2010. Available at; 93.pdf Last accessed 19.05.10 

2. Data on File - IPSOS-UK April 2004 

3. Fowler G. Smoking: Time to confront a major health issue, Update Supplement 
2000: 3-7 

4. Royal Pharmaceutical Society of Great Britain. Community Pharmacy the Untapped Primary Care 
Resource. 2007. 

Available at: Last accessed 25.05.10 

5. Hjalmarson A, et al. Arch Intern Med. 1997; 157: 1721-172 

6. Tonnesen R et al. JAMA 1993; 269: 1268-1271 

7. Schneider NG, et al. Addiction 1996; 91(9): 1293-1306 

8. Leischow SJ, et al. Am J Health Behav 1996; 20(5): 364-371 

9. Nicorette Inhalator Summary of Product Characteristics 

10. Fagerstrom. Can reduced smoking be a way for smokers not interested in quitting to actually quit? 
Respiration 2005; 72: 216-20 

1 1 . McNeil products limited data on file - CDTS 001 


Smoking cessation - one step at a time 

Five out of 10 smokers are not happy with their 
current smoking habit. 2 So that the support given to 
smokers is well-matched to their individual needs, 
pharmacists should consider the following ways of 
helping their customers: 

• 'Abrupt Quitter' strategy - a smoker who is able to 
stop smoking immediately often with the help of 
NRT and behavioural support. 

• 'Reduce to Stop' strategy - used to encourage 
those who are not 'abrupt quitters' to build 
towards a quit attempt by gradually reducing the 
number of cigarettes used. 

• 'Safer Option to Smoking ' strategy - used 
for those unwilling or unable to quit smoking 
by replacing some cigarettes with Nicorette' 
Inhalator, a safer option to smoking for when 
smokers are not yet ready to break free from 

Nicorette " Inhalator can now be used in a novel 
way which will help those smokers who 'cannot quit 
yet' to replace some cigarettes, as a safer option to 
smoking. Pharmacists can help patients, who have 
previously felt they cannot quit, take the first step on 
their journey with the end goal - smoking cessation - 
in sight. 

Community pharmacists are encouraged to advise 
on the correct use of nicotine replacement therapy 
(NRT) products and to provide behavioural suppoit 
to aid smoking cessation. 

For further information on the Nicorette Inhalator 

lacists are in an ideal position to 
age the use of the Nicorette Inhalator 
mokers including those who continue to 
, which supports smoking reduction as the 
?p to cessation. Smoking cessation is no 
about either quitting or not, but instead 

be seen as a continuous process that can 

several stages. " 

Stephen Foster, Pharmacist, Kent 

McNeil j 

Nicorette Inhalator Product Information: 

Presentation: Inhalation cartridge containing 10mg nicotine for 
oromucosal use via a mouthpiece. Uses: Relieves and/or prevents 
craving and nicotine withdrawal symptoms associated with tobacco 
dependence. It is indicated to aid smokers wishing to quit or reduce prior 
to quitting, to assist smokers who are unwilling or unable to smoke, and 
as a safer alternative to smoking for smokers and those around them. 
It is indicated in pregnant and lactating women making a quit attempt. 
Dosage: Adults and Children over 12 years of age: Nicorette Inhalator 
should be used whenever the urge to smoke is felt or to prevent cravings 
in situations where these are likely to occur. Smokers willing or able 
to stop smoking immediately should initially replace all their cigarettes 
with the Inhalator and as soon as they are able, reduce the number of 
cartridges used until they have stopped completely. Smokers aiming to 
reduce cigarettes should use the Inhalator, as needed, between smoking 
episodes to prolong smoke-free intervals and with the intention to reduce 
smoking as much as possible. As soon as they are ready smokers should 
aim to quit smoking completely. When making a quit attempt behavioural 
therapy, advice and support will normally improve the success rate. 
Those who have quit smoking, but are having difficulty discontinuing 
their Inhalator are recommended to contact their pharmacist or doctor for 
advice Contraindications: Children under 12 years and Hypersensitivity. 
Precautions: Unstable cardiovascular disease, diabetes mellitus, G.I 
disease, uncontrolled hyperthyroidism, phaeochromocytoma, hepatic 
or renal impairment, chronic throat disease, obstructive lung disease or 
bronchospastic disease. Stopping smoking may alter the metabolism 
of certain drugs. Transferred dependence is rare and both less harmful 
and easier to break than smoking dependence. May enhance the 
haemodynamic effects of. and pain response to, adenosine. Keep out of 

reach and sight of children and dispose of with care. Best used at room 
temperature. Pregnancy & lactation: Only after consulting a healthcare 
professional. Side effects: Cough, irritation of throat and mouth, 
headache, nasal congestion, nausea, vomiting, hiccups, palpitations. 
Gl discomfort, dizziness, reversible atrial fibrillation. See SPC for further 
details. RRP (ex VAT): 6-Starter pack £6.64, 42-Refill pack £20.89. Legal 
category: GSL. PL holder: McNeil Products Ltd. Roxborough Way. 
Maidenhead, Berkshire. SL6 3UG. PL number: 15513/0179. Date of 
preparation: March 2010 

Nicorette Gum Product Information 

Presentation: Nicorette 4mg gum and Nicorette 2mg gum contain 4mg 
and 2mg of nicotine respectively in a chewing gum base. Original, Mint, 
Freshmmt, Freshfruit and Icy White flavours. Uses: Relief of nicotine 
withdrawal symptoms as an aid to smoking cessation. Used to help 
smokers ready to stop smoking immediately and also smokers who need 
to cut down their cigarette use before stopping. Dosage: Adults (over 18 
years): No more than 15 pieces of gum should be used each day. Use 
when there is an urge to smoke. Patients smoking 20 or less a day should 
use 2mg gum. Those smoking more than 20 should use 4mg gum. Each 
piece should be chewed slowly for about 30 minutes. Smoking cessation: 
Patients should stop smoking during treatment. After up to 3 months ad 
libitum dosage. Nicorette gum use should be gradually reduced. Those 
who use NRT beyond 9 months should consult a healthcare professional. 
Smoking reduction: Use the gum between smoking episodes to reduce 
smoking. A quit attempt should be made as soon as the smoker feels 
ready but no later than 6 months. Professional advice should be sought if 
no reduction in 6 weeks or no quit attempt in 9 months. Adolescents (12 

to 18 years): No more than 15 pieces of gum should be used each day. 
Smoking cessation: After 8 weeks ad libitum dosage, reduce gum use over 
4 weeks. If not stopped by 12 weeks, a healthcare professional should 
be consulted. Smoking reduction: Only after consulting a healthcare 
professional. Under 12 years: Not recommended Contraindications: 
Hypersensitivity, Precautions: Denture wearers. Gl disease, unstable 
cardiovascular disease, diabetes mellitus. uncontrolled hyperthyroidism, 
phaeochromocytoma, renal or hepatic impairment. Stopping smoking 
may alter the metabolism of certain drugs. Transferred dependence is 
rare and less harmful and easier to break than smoking dependence. 
May enhance the haemodynamic effects of. and pain response to, 
adenosine. Keep out of reach and sight of children and dispose of 
with care. Pregnancy & lactation: Only after consulting a healthcare 
professional. Side effects: Headache, sore mouth or throat, jaw-muscle 
ache, Gl discomfort, hiccups, nausea, vomiting, dizziness, erythema, 
urticaria, palpitations, allergic reactions, reversible atrial fibrillation. See 
SPC for further details RRP (ex VAT): 2mg gum (10) £2.84, (30) £4.83, 
(105) £13.23, (210) £22.07; 4mg gum (30) £5.94, (105) £16.12, (210) 
£27.16. Icy White 2mg gum (30) £5.08, (105) £13.96; 4mg gum (105) 
£17.09. Legal category: GSL. PL numbers: Original 2mg 15513/0169. 
4mg 15513/0170; Mint 2mg 15513/0171, 4mg 15513/0172; Freshmmt 
2mg 15513/0173, 4mg 15513/0174; Freshfruit 2mg 15513/0136, 4mg 
15513/0137; Icy White 2mg 15513/0152; 4mg 15513/0153. PL holder: 
McNeil Products Ltd, Roxborough Way, Maidenhead, Berkshire, SL6 
3UG. Date of preparation: March 2010 

Date of preparation May 2010 




TV ad focus for Panadol Advance 

Did a mostly 
unseasonably warm 
May boost your sales? 

"It certainly 
had an 
effect on 
our so- 
but not 
much else." 
Colin Dougall, lloydspharmacy, 
Drumchapel, Glasgow 

"We definitely 
saw an 
increase in 
sales in certain 
products like 
sun cream, but 
then we sold 
fewer products 
like cough medicine so it was pretty 
much the same overall." 
Bhavesh Pate!, Pharma 
Healthcare, Canvey Island, Essex 

Panadol Advance 
will be the focus of a 
£1 million television 
campaign this 
summer, CSK 
Consumer Healthcare 
has announced. 

The nine-week 
campaign starts next 
week and will run 
through July and 
August on both satellite and 
terrestrial channels. 

A combination of 10- and 20- 
second television adverts will 

demonstrate how the brand's unique 
disintegration system disperses in 
the stomach up to five times faster 
than ordinary paracetamol, 

according to the company. 

The adverts will highlight Panadol 
Advance's Pain Relief Product of the 
Year 2010 win in the Product of the 
Year Awards. 

Advertising will also appear in 11 
print titles including Woman's Own 
and Take a Break throughout the 
campaign period. 

Prices: £1.45/16; £2.79/32 
Pip codes: 340-6535; 340-6543 
CSK Consumer Healthcare 
Tel: 0845 762 6637 

Vertese supplements get wider distribution 

Vegetarian supplement producer 
Vertese has announced it will now 
be distributing its range through 
Fortuna Healthcare. 

The company says the move will 
allow pharmacists to tap into a new 
revenue stream, and with the benefit 

of a larger distribution anticipates it 
will be able to offer guaranteed 
supply of its range. 

The range includes omega oils 3, 6 
and 9, glucosamine and flaxseed oil, 
evening primrose oil and flaxseed oil 
supplements, and has been 

Email your letters to haveyour 

Cut the red tape to flourish 

Yes 33% 


Armchair view: Most pharmacists 
noticed no warm weather rise in 
their sales last month. However, 
seasonal lines did receive a boost, 
according to some. 
Next week's question: 
Should higher protection factor sun 
cream cost the same as lower 
factors? Vote at 

Having just filled the Electronic 
Prescription Service release 2 smart 
card application form, it just 
occurred to me that Her Majesty 
The Queen would not be able to 
qualify. She has no photo ID or any 
utility bills in her name at her 
official residence! 

We as a nation have lost our 
sense of proportion. Every 
procedure has to be tied up in belt 
and braces just in case, to cover an 
eventuality which may occur once 
in a million years! 

To have a dynamic enterprising 

approved by the Vegetarian Society. 

Prices and Pip codes: See C+D 
Price List or 
Fortuna Healthcare 
Tel: 0208 805 7805 

Moorf ields to 
[rcatlciytrach lube 

Moorfields Pharmaceuticals is 
relaunching dry eyes treatment 
llube. The company acquired the 
brand in May and is in the process of 
redesigning the packaging. 

Moorfields says it plans to focus on 
dry eye syndrome and launch other 
treatments over the next 24 months. 

Anyone experiencing problems 
with llube supply should contact the 
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for further information. 

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£1m TV ad campaign 
boosts OdorEaters 

Combe International has announced 
its OdorEaters brand will be the 
focus of a five-week television 
campaign from this week 

The company has increased its 
spend on OdorEaters advertising to 
over £1 million as part of a £10m 
investment in Combe's key brands 
throughout 2010. 

The advertising campaign follows 
the launch of OdorEaters Sport Foot 
& Shoe Spray last month. 

The spray contains an 
antibacterial that helps to kill odour- 
causing bacteria in sports shoes and 
trainers, plus an antiperspirant, 
according to the company. 

Price £4.49/150ml 

Pip codes: 351-5681 

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Tel: 020 8680 2711 

J u vela offers fresh bread rolls 

Juvela has launched Gluten-Free 
Fresh White Rolls and Gluten-Free 
Fresh Fibre Bread Rolls. 

The Fresh Fibre Bread Rolls are 
high in fibre, contain crushed 
linseeds and can be eaten straight 

from the bag, according to the 

Juvela's Fresh Fibre Bread was 
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Foods Matter Free From Food 
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and they are delivered in cases of 
eight in the white or fibre variety. 

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On TV next week 


Flomax Relief MR: ITV, five, Sat 
Jungle Formula: All areas 
Lanacane Anti Chafing Gel: All areas 
Magicool: GMTV, ITV, five 
Magicool Plus: GMTV, ITV, five 
OdorEaters: All areas 
Savlon: All areas 
Seabond: All areas 

PharmaSite for next week: Zirtek - windows, Zirtek- in-store, 
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26.06.10 Chemist* Druggist 15 


What do you think? 

A lie told often enough becomes the truth 


I try hard, really I do. Each week I scan the pages 
hoping against hope that the reports will be 
different, but still I alternate between anger and 
despair from what I read. Usually this is the 
Sunday papers - those folios of everything that is 
wrong with the world, written in advance by 
journalists confident of little real news at the 
weekend - but more recently I've meant the 
pharmaceutical press. 

A month ago came the infamous BMJ article 
that lambasted community pharmacy for being 
driven by avarice alone, and while such articles 
themselves have brief currency, it did come up 
with a phrase that I can see being bandied about 
for quite a while - 'the for profit pharmacy sector'. 
Those using this insidious little idiom remember 
Lenin saying that a lie told often enough becomes 
the truth, and thus this expression surfaced at the 
recent LMC conference that demanded full 
dispensing rights for GPs - who apparently are 
'suffering' while the 'for profit' pharmacists grow 
rich, presumably as the NHS simply lavishes 
money upon us. 

Leaving aside this envy and bare-faced cheek of 
a self-evidently affluent profession, content to 
milk their supposed primary care colleagues by 
engendering a local bidding war for a space under 
their roof to run an understaffed prescription 
factory at a loss as rental costs per square metre 
exceed that of Mayfair and Knightsbridge -the 
LMC motion is wrong in so many ways. What it 

missed is that CPs and pharmacists in business 
want the same thing - an equitable and secure 
practice where the rewards follow the quality and 
service provided, not just whoever can do the best 
deal or has the most capital behind them. If 
patients really are at the forefront of NHS 
planning, then we know they need easy access and 
the familiarity of a consistent, high-quality clinical 
service. This means clinicians investing in premises 
and staff, and that only happens when you feel 
secure about your business. 

So the fault is not with the 'for profit' 
pharmacy sector, or the 'for profit' GP sector, 
but with a control of entry system that serves 
the entrepreneur or the cash-rich conglomerate 
rather than the patient. 

The current regulations are outmoded and 
outdated, the only recent change brought about 
by the empire building of a cheap grocer who saw 
pharmacy as rich pickings, and when it was proven 
neither necessary nor desirable for a pharmacy to 
be located next to his baked beans, he muscled 
the OFT into providing loopholes for entry. 

PSNC needs desperately to parlay for common 
ground with the LMC, because if this call is taken 
up in parliament I fear that MPs could be sold a 
quick and easy compromise of yet another control 
of entry exemption that allows a contract for any 
surgery. That could create a whole new phrase - 
the 'not for profit' pharmacy sector, and I know 
who will be suffering then. 

No place to hide when it comes to MURs 

I know how many medicines use 
reviews you have carried out each 
month. Yes, you. 

You might have been under the 
impression that MUR figures are 
confidential. However, the Freedom 
of Information Act 2000 gives a 
right to see information held by any 
public authority. According to the 
Act, a public authority includes the 
NHS Business Services Authority, 
any PCT or LHB, and any person 
providing pharmaceutical services or 
primary medical services. 

Information requested from a 
public body must be supplied 
promptly and in any event within 20 
working days. Some information is 
exempt from disclosure, such as 
information that, if disclosed, would, 
or would be likely to, prejudice the 
commercial interests of any person. 
The Business Services Agency plainly 
doesn't regard disclosing MUR data 
as prejudicial to the commercial 
interests of any pharmacy business. 
Indeed, it seems that the NHS 

Business Services Authority has had 
so many requests for disclosure of 
the MUR figures of individual 
pharmacies that the data are just 
posted on its website to save having 
to answer individual requests 
for information. 

Some applicants for pharmacy 
contracts routinely find out how 
many MURs are carried out by 
existing local pharmacies in case the 
number indicates that current 
services are inadequate. MUR figures 
won't always be relevant because a 
need for MURs will depend on local 
demographics, such as the age 
profile of a neighbourhood. However, 
I recently succeeded in obtaining a 
pharmacy contract for a client in a 
small town that had two pharmacies, 
both owned by the same proprietor. 
One of the pharmacies was almost 
next door to the two CP practices 
in town. Hardly any MURs had 
been carried out at the existing 
pharmacies, and although this was 
partly explained by the absence until 

recently of a consulting room in one 
of the pharmacies, the Family Health 
Services Appeal Unit was not 
convinced that the owner of the 
existing pharmacies would provide a 
full range of services. 

Using MUR figures in NHS 
contract applications is 
symptomatic of the current interest 
in developing services other than 
dispensing. While there is a lot of 
talk these days about quality, it is 
much easier to measure quantity. 

It remains to be seen whether the 
same kind of information will be 
useful after next spring, when the 
current focus of the control of entry 
regime shifts away from providing 
people with adequate services and 
towards the contents of PNAs. 
David Reissner is a specialist in 
pharmacy law and head of 
healthcare at Charles Russell LLP 
Contact him on 0207 203 5065 
or email david.reissner@ 


16 Chemist Druggist 26.06.10 

Easy Freezey 

Different sized warts and verrucas need 
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19 Pregnancy ► 22 Glucosamine ► 26 Methadone ► 28 Cat M ► 30 Team morale ► 32 LPCs 

Pregnancy part A: giving birth 

The three stages of labour, induction methods and drugs for pain relief 

Supported by 



Katharine Gascoigne MRPharmS 

Spontaneous labour usually occurs after about 
40 weeks of pregnancy and is divided into three 

Signs that labour may start soon include 
engagement of the baby's head, strong Braxton 
Hicks contractions and loss of the mucous plug 
that has been blocking the cervix - this is known 
as the "show". In 15 per cent of pregnancies 
the waters break, either suddenly or gradually, 
before contractions start. A woman is classed as 
being in true labour once her cervix has dilated 
beyond 2-3cm and she is experiencing regular 

The first stage of labour is itself divided into 
three phases. The first is the latent phase when 
uterine activity begins; contractions are usually 
mild and irregular, and the cervix thins and softens 
(effacement). This phase can last for many hours, 
especially in first-time mothers. Pain may present 
in the lower back and there is often the need to 
empty the bowels. 

The active phase is said to have started once the 
cervix is at around 3cm and regular, stronger 
contractions are established. The nature of the 
contractions changes and the pain shifts from just 
the lower part to the whole of the uterus. 
Contractions become more regular until they 
occur every two minutes, with each one lasting 
around 60-90 seconds. 

The duration of this stage varies according 
to whether a woman has had a baby before. In 
first-time mothers the cervix dilates an average 
of 1cm each hour, but it is much faster in 
subsequent labours. If the waters have not broken 
spontaneously and the cervix has reached about 
5cm they may be broken artificially to release 
prostaglandins which, together with the increased 
pressure of the baby's head against the cervix 
following removal of the amniotic fluid, causes 
contractions to speed up. 

The final phase of the first stage of labour is 
known as transition and begins when the cervix 
reaches 10cm and is fully dilated. This phase may 
only last minutes or can go on for more than an 
hour. Contractions are very intense and long, and 
the woman often feels a strong urge to push. This 
is a sign she is entering the second stage of labour. 

Once the cervix is fully dilated the mother, with 
advice from the midwife, pushes the baby's head 
downwards into the pelvis with each contraction. 
Gradually the baby's head appears (this is called 

crowning) and at this point it usually only takes a 
few more contractions for the head, shoulders 
then the rest of the body to be delivered. For first 
labours this stage lasts an hour on average but in 
subsequent labours it lasts just minutes. 

Throughout the second stage the baby's heart 
is monitored after each contraction or push. The 
contractions are also monitored, as they 
sometimes fade away - in which case a low-dose 
syntocinon (a synthetic equivalent of oxytocin) 
infusion is used to restore strong, regular 

If the second stage takes too long an episiotomy 
(a cut through the perineum) or the use of forceps 
or vacuum extraction (ventouse) may be 

The third stage 

The final stage of labour involves the delivery of 
the placenta and membranes. Once the umbilical 
cord has been cut, the placenta must be delivered 
promptly. This stage is usually managed with an 
injection of Syntometrine, a combination of 
syntocinon and ergometrine. It is injected into the 
woman's thigh muscle as soon as the baby's head 
and first shoulder are delivered. It works by 
initiating a strong sustained contraction so that 
the placenta separates from the uterus and begins 
to be expelled. The midwife carefully pulls the 
umbilical cord until the placenta and membranes 
are delivered. 

Without the injection, delivery of the placenta 
still occurs naturally but takes longer and is 
associated with increased risk of haemorrhage. 

If a pregnancy goes beyond 40 weeks it is 
overdue. At 41 weeks an examination of the cervix 
may be offered and a membrane sweep 
performed. This involves the midwife sweeping a 
finger around the cervix in order to release 
prostaglandins and hopefully kick-start labour. 

Induction is recommended if labour has not 
started by 42 weeks. Beyond this point the risk of 
foetal distress and stillbirth increases because of 
decreased functioning of the placenta and 
increased size of the baby. 

Induction is also indicated if the baby is 
distressed, if there are maternal complications, or 
if the waters break but contractions do not start 
within 24 hours. Induction is only used when 
necessary as it is unpredictable and there is less 
chance of a normal vaginal delivery. 

As long as the baby is head-down and engaged 
or nearly engaged, a prostaglandin pessary or gel is 
inserted into the vagina to ripen the cervix if 
necessary. This is repeated after six hours and 

26.06 10 




20 Pregnancy r 22 Glucosamine ► 26 Methadone ► 28 Cat M ► 30 Team morale ► 32 LPCs 

Once the umbilical cord is cut, the placenta must be delivered promptly to decrease the risk of haemorrhage 

subsequently if needed. The baby is monitored for 
30 minutes after each dose. Artificial rupture of 
membranes (ARM) may be offered once the cervix 
is 2-3cm dilated. This releases prostaglandins, 
which aid contractions and may be enough to get 
labour started. If not, a syntocinon drip is started 
to stimulate the uterine muscles to contract. An 
initial low dose is gradually increased until 
contractions are established at around three every 
10 minutes. 

This rapid start of contractions means that 
continuous monitoring of the baby and mother are 
required and often an epidural is recommended. 

Caesareaii section 

At least one in five babies in Britain are born via 
caesarean section, either electively or as an 
emergency. Most elective caesareans are 
performed because vaginal delivery is considered 
risky for the mother or baby, and the reasons 
include breech presentation (the baby is bottom- 
down), placenta praevia (when the placenta 
covers the cervix), multiple pregnancy, maternal 
illness and pre-eclampsia. 

Emergency caesareans may be performed when 
the progression of labour is considered to be too 
slow or when there is foetal distress. Caesareans 
are usually performed under epidural or spinal 
block, but general anaesthetic may be needed. 

Pain relief 


During the very early stages of labour, 
paracetamol may be used to ease the pain of 
contractions. The next step is Entonox, which is a 
50:50 mix of nitrous oxide and oxygen (referred to 
as gas and air). It does not give complete pain relief 
but makes the contractions more bearable, is quick 
to work and wears off quickly after use, and can be 
used in home births. It does not sedate the mother 
but may make her feel light-headed and nauseous. 

The woman is in full control and should be 
advised to start taking deep slow breaths when she 
feels the contraction beginning. There are no 
harmful side effects to the baby. 

Most women find gas and air beneficial during 
the early stages of labour but, as it progresses and 
contractions become stronger, extra pain relief 
may be desired. 

Opioids are the next step in managing pain. 
While any opioid can be used, pethidine is the 
most common as it can be prescribed and 
administered by midwives. An intramuscular 
injection of pethidine works within 15-20 minutes 
and lasts for around three to four hours. There are 
a number of disadvantages to using opioids during 
childbirth because, as well as causing sedation, 
nausea and vomiting in the mother, they cross the 
placenta causing drowsiness in the baby leading to 
problems in establishing breastfeeding. If given too 
close to birth the baby may suffer sedation and 
breathing difficulties for which an injection of 
naloxone is indicated. 

For complete pain relief an epidural is used. It 
has to be administered by an anaesthetist. A 
traditional epidural involves an injection of local 
anaesthetic (sometimes in combination with an 
opiate) through a catheter into the epidural space 
in the spine. 

The mother's blood pressure is checked regularly 
after an epidural, as hypotension is a common side 

effect caused by the anaesthetic blocking the 
nerves that control blood vessels in the legs and 
pelvis. An intravenous drip is always inserted 
before an epidural, to allow administer fluids to be 
given if necessary. A catheter is also often inserted 
because the nerves that control the bladder are 
also blocked. 

Full anaesthesia should be achieved after 20-30 
minutes and may be topped up when required, 
usually every three to four hours. Some hospitals 
offer mobile epidurals where a lower dose of 
anaesthetic is used. These leave the legs 
unaffected so that the woman can remain mobile 
and without need of catheterisation. 

An epidural should not cause drowsiness or 
nausea in the mother and the anaesthetic does not 
cross into the placenta. However, contractions 
cannot be felt, which makes pushing at the right 
time and in the correct way difficult. As the final 
stage is approached, the dose of anaesthetic may 
be reduced to avoid this problem and reduce the 
risk of intervention. 

Some women develop a headache, backache, 
tingling or numbness in their legs after the 
epidural. These ease over time, although some 
believe epidurals can cause long-term back pain. 

Most women are able to ease the pain of early, 
mild contractions using deep breathing techniques 
and by staying mobile. 

Probably the most popular of the drug-free 
methods of pain relief is a TENS machine 
(transcutaneous electrical nerve transmission), 
which conducts a small electric current through 

the skin to stimulate production of endorphins, 
which block nerve transmission to the brain. 
Specific maternity TENS machines are provided by 
some hospitals or are available for rental from 
pharmacies. They are easy to use, the woman is in 
complete control and able to remain mobile, and 
there is no effect on the baby. They cannot be used 
in water, however. 

Hydrotherapy in a bath or a birthing pool is 
increasingly recognised as a good way to ease the 
pain of contractions. The warmth of the water aids 
relaxation and the buoyancy gives support and 
relieves the pressure of the baby's head in the 
pelvis. Extended periods in water are usually not 
recommended once the waters have broken and in 
most cases the baby will be delivered out of water 
unless the midwife is experienced enough to 
deliver the baby under water. 
Katherine Cascoigne MRPharmS is 
a part-time locum and pharmacy writer 

Download a CPD log sheet that helps you 
complete your CPD entry when you 
successfully complete the 5 Minute Test for 
this Update article online (p21). 


1. Regan, L (2005). Your pregnancy week by week. 
London: Dorling Kindersley. 

2. NHS Choices (2010) 

3. Mumsnet (self-help group) (2010) 

4. National Childbirth Trust (2010) 


The first of two articles on the 
diagnosis, causes and treatment 
of rheumatoid arthritis 


mst 26.06.10 

Sign up for the CPD newsletter at 

What is syntocinon and when is it administered? When 
might induction of labour be recommended? What are 
the advantages and disadvantages of using pethidine in 
labour? How does a TENS machine work? 

This article describes the three stages of labour and 
includes information about induction, caesarean section 
and the use of drugs to aid labour. It also discusses 
pharmacological and non-pharmacological pain relief 
such as pethidine, Entonox and TENS. 

Find out more information about the stages of labour 
on the Mumsnet website at, and 

Read more about induction and augmentation of 
labour on the National Childbirth Trust website at 

Read more about caesarean section on the Mumsnet 
website at 

8 Find out more about pain relief in labour from the 
Patient UK website at and 
revise your knowledge of TENS machines from the same 
website at Think about 
the advice you could give to expectant mothers. 

Are you now familiar with what happens during the three 
stages of labour? Do you know what drugs might be 
used? Are you confident in your ability to discuss pain 
relief in labour with a patient? 

Registering for Update 2010 costs £37.60 (inc VAT) and can be done easily 
at or by calling 0207 921 8425. 

Signing up also ensures that C+D's weekly Update article is delivered 
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Get a CPD log sheet for your portfolio when you successfully complete 
the 5 Minute Test online. 

Advice on preventing osteoporosis 

At the Update Pharmacy, relief 
pharmacist Lydia Allen is on duty. 

During a quiet period in the 
dispensary she and dispensing 
technician Brenda are chatting. 
Brenda says: "Lydia, I'd like some 
advice about reducing my chances of 
developing osteoporosis. My poor old 
mum has it really badly and I don't 
want to follow in her footsteps." 

"Can you give me a bit of 
background about your mum?" Lydia 

"Well, I suppose it started with my 
mum having an early menopause 

when she was only 40. She started 
taking HRT, but had to stop it due 
to thrombosis. She then began to 
suffer pain in her spine. She 
eventually had a bone density scan 
and was diagnosed as suffering from 
severe osteoporosis. 

"She's been on a bisphosphonate 
ever since but it was too late; she 
now has a hunchback which causes 
severe back pain and prevents her 
from sitting for long periods. Her 
appearance has changed 
considerably - she's about two 
inches shorter than she used to be. 
She has problems finding nice 
clothes and can only wear flat shoes 
because she daren't risk having a fall. 

"I just don't want to end up like 
her. I know I'll need to get a bone 
scan, but I want to know what I can 
do for myself to reduce my chances 
of getting it." 


1. What are the main controllable 
and uncontrollable risk factors 
for osteoporosis? 

2. Which drugs can increase the 
risk of osteoporosis? 

3. What lifestyle measures can 
reduce the risk? 

4. Can vitamin and mineral 
supplements reduce osteoporosis 


1. Controllable: alcohol intake 
greater than four units/day; 
smoking; poor diet (particularly if 
calcium deficient); being 
underweight (less than 19 kg/m 2 ); 
very sedentary lifestyle. 
Uncontrollable: increasing age; 
female gender (prevalence in 
women is four times greater than in 
men); Caucasian or Asian ethnicity; 
parental history of hip fracture; 
rheumatoid arthritis; corticosteroid 
therapy; Crohn's disease; untreated 
premature menopause (under 45 
years); malabsorption syndromes, eg 
coeliac disease; hyperthyroidism. 

2. Long-term oral or high-dose 
inhaled corticosteroids; excessive 
dosage of thyroid replacement 
hormones; anti-epileptics including 
phenytoin and carbamazepine; some 
drugs to treat endometriosis, eg 
nafarelin; aromatase inhibitors for 
breast cancer, including anastrozole 
and letrozole; SSRIs; long-term 
parenteral medroxyprogesterone for 
contraception; long-term heparin. 

3. Stop smoking; limit alcohol 
intake; eat a balanced, calcium-rich 
diet - reducing intake of protein and 
carbonated drinks reduces calcium 
loss; increase vitamin D by getting at 
least 15 minutes exposure to the sun 
each day; undertake weight-bearing 
and resistance exercise, eg walking, 
hiking, jogging, climbing stairs, 
racquet games, dancing, lifting free 
weights and using weight machines, 
at gyms and health clubs. 

4. The BNF recommends that those 
at risk of osteoporosis should 
maintain an adequate intake of 
calcium and vitamin D. Other 
vitamins and minerals believed to be 
necessary for bone health include 
vitamins C and K, magnesium, 
boron, silicon, zinc and copper. 

Do you have an idea for a Practical 
Approach scenario or would you 
like to write one? Email us at: 

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to you every week, sign up to C+D's 
free CPD bulletin at www.chemist 

26.06.10 Chemist-Druggist 21 




119 Pregnancy : : 22 Glucosamine 26 Methadone : 28 Cat M 28 Team morale 32 LPCs 

Glucosamine: the 
evidence exposed 

The evidence for glucosamine as an osteoarthritis treatment remains mixed, 
despite the launch of a prescribable product. Gavin Atkin presents the case 

I t may not be a vitamin or mineral, and the 
evidence for its effectiveness may be mixed 
- but the nutritional supplement 
glucosamine continues to be big news. 

Glucosamine is a well established product 
that's very popular with the public. For years it 
has been sold as a nutritional supplement and 
complementary therapy; however, early this year 
brought the launch of Dolenio, a prescribable 
product containing a daily dose of 1,500mcg of 
glucosamine sulphate. 

The move might be thought to have lent the 
product a new respectability -yet the authors of 
the Nice osteoarthritis guidelines published in 
2008 concluded that glucosamine could not be 
recommended as cost-effective for the NHS. 

So what exactly is this mysterious stuff that 
divides medical opinion, and that the public 
seems to love? 

Glucosamine is an aminosaccharide usually 
produced by extraction from shellfish. In the body 
it's a precursor in the synthesis of the 
glycosaminoglycans and glycoproteins found in 
ligaments, tendons, cartilage and synovial fluid. 

It's sold in the form of capsules and cream, 
either a sulphate or hydrochloride, and the 
theory, backed by some evidence from animal 
studies, is that glucosamine supplementation 
can delay or even repair joint degradation in 

It's also relatively inexpensive and generally free 
of unwanted side effects - unless the patient is 
allergic to shellfish, the only concern seems to be 
a number of reports suggesting an interaction 
between glucosamine and anti-diabetic 
treatments leading to an increase in blood sugar 
levels and requiring changes to diabetes therapy. 

The big question over glucosamine, however, 
relates to the evidence for its effectiveness in 
humans. Last year, an Arthritis Research UK review 
of complementary therapies reported that the 
majority of the 21 or so trials that have evaluated 
glucosamine sulphate demonstrated significant 
clinical benefits compared to placebo or NSAIDs. 
However, another commonly sold form, 
glucosamine hydrochloride, was less well 
supported by evidence, the organisation said. 

But despite Arthritis Research UK's efforts to 
find a definitive answer, the debate over 
glucosamine is still some way from being settled, 
as Arthritis UK spokesperson Jane Tadman 
explains: "It's fair to say that the medical 
profession is divided, for probably very good 

"The big question 
relates to the evidence 
for glucosamine's 
effectiveness in 

"There was a famous study in the Lancet that 
showed benefits in terms of improved joint 
spacing and pain. That was the point when we 
decided there was enough evidence to include 
glucosamine advertising in our magazine - we 
have a strong policy that only products that have 
been proven to work are allowed to advertise. 

"But since then clinical trials have been very 
mixed. We did hope the GAIT trial in the States 
would finally answer the question of whether 
glucosamine works or not, but the results from 
that study could be interpreted almost any way 
you wanted; there were subgroups who did quite 
well on glucosamine, while people in the main 
body of the trial didn't do well at all. 

"The manufacturer of the glucosamine 
treatment in the trial took the results as 

supporting their claims for the product, while 
others concluded that we still don't know whether 
it works or not." 

Ms Tadman adds: "There still hasn't been a 
definitive study showing glucosamine really helps. 
But anecdotally a lot of people find it very useful - 
it's a huge seller, people buy it in large numbers." 

Quality control 

Why should the trial results differ from anecdotal 
evidence? The maker of Dolenio is clear - the 
reason for many of the failures is less likely to be 
that the treatment doesn't work than because the 
treatments that many patients have taken have 
not been made to pharmaceutical standards. 

"When we started selling glucosamine as an 
ingredient in the UK, we started visiting the 
typically small supplement-producing factories 
manufacturing the tablets and were quite 
surprised to see the quality of the tablets being 
produced," says Sundeep Aurora, president of 
Dolenio manufacturer Bioplus. 

"These were not pharmaceutical manufacturers 
but typically food supplement manufacturers, 
often new start-ups. It was a young industry and 
the knowledge of how to produce a complicated 
product like glucosamine was lacking." 

A key problem was glucosamine's acidity. "The 

22Chemi 26.06.10 

Get CPD resources straight to your inbox 

Key points 

• Glucosamine is an aminosaccharide usually produced 
by extraction from shellfish 

• It is a precursor in the synthesis of 
glycosaminoglycans and glycoproteins found in 
ligaments, tendons, cartilage and synovial fluid 

• Evidence from animal studies suggests glucosamine 
supplementation can delay or repair joint 
degradation in osteoarthritis 

• The clinical evidence for such benefits in humans 
is still inconclusive 

• Nice 2008 guidelines did not recommend 
glucosamine as cost-effective for the NHS 

Further reading 

glucosamine component has a low pH of between 
4 and 5, and there are lots of complications in 
manufacturing something like that - though if 
you're a pharmaceutical company it's pretty 
standard stuff," Mr Aurora says. "It's also 
hygroscopic, and there is potential for free acid 
release, which leads to discoloration and 
metabolites forming in the product." 

Degradation studies, which are required for 
pharmaceutical products, aren't needed for 
nutritional supplements, he adds, and so with 
these products there's no clear guarantee in 
relation to what happens to the product on the 
shelf overtime. 

"Even today, if you buy food supplements 
containing glucosamine, if they haven't been 
carefully produced you will find that within a few 
months the product becomes yellow, light brown 

or even black. At this point the product's likely to 
be less effective, and it's not clear what the by- 
products of the degradation might be." 

But Ms Tadman adds: "The good thing about 
glucosamine is that it has few side effects, and 
anyone who tries it is unlikely to be putting 
themselves at any risk." 

Given that the studies are not showing large 
effects, it seems logical that patients should be 
warned not to expect too much. But on balance, 
Ms Tadman says, glucosamine is probably worth a 
punt for many patients - unless they are allergic 
to fish or have diabetes. 

"Patients should not expect glucosamine to be 
a miracle cure," she concludes, "but they should 
probably give it a try, as it's not expensive. 
However, our advice would be not to buy dodgy 
products via the internet." 


Complementary and alternative medicines 
for the treatment of rheumatoid arthritis, 
osteoarthritis and fibromyalgia 


Glucosamine/chondroitin arthritis 
intervention trial (GAIT): primary and 
ancillary study results research/ results/gait/ 

; (2008) The care and management of 
osteoarthritis in adults 

CPD Reflect • Plan • Act • Evaluate 

Special team. 

Special service. 
Special number. 

BCM Specials have over 70 years experience of manufacturing 
unlicensed medicines. Our Customer Care team take special care 
of your order to make sure you get it right on time, every time. 

Call us for our expert advice 8am - 5.30pm Monday - Friday: 

0800 952 1010 

There's only one team and one number you can trust. 
Place an order 24 hours a day, 7 days a week 



3800 085 0673 

A new POm to P' solution for heartburn 

Pantoloc Control is a new OTC treatment for the burning problem of acid 
reflux. Containing pantoprazole 20mg, this new 'POM-to-P' switched 

medicine can be recommended as a first choice treatment for 
frequent sufferers experiencing two or more episodes 
of heartburn or acid regurgitation a week. 

Between 10-20 per cent of people in the UK experience acid reflux at least 
weekly, 1 and it can impact on quality of life, leading to avoidance of certain 
foods and drinks, and loss of sleep. 

Some 80 per cent of regular heartburn sufferers complain of night-time 
heartburn. Over 70 per cent of these people take OTC medicines for relief, but 
less than a third consider them to be 'extremely effective'. 2 
NICE Guidelines 1 ' recommend that for many patients self-treatment with antacid 
and/or alginate therapy may be appropriate for immediate symptom relief. However, 
additional therapy is appropriate to manage symptoms that persistently affect quality of life. 

As a new and effective OTC treatment that stops stomach acid secretion at source, Pantoloc 
Control offers more complete and sustained relief from acid reflux symptoms than other OTC 
treatments such as antacids and H2 antagonists. 

Give your customers the benefits of Pantoloc Control 

For short term treatment of reflux symptoms such as heartburn and acid regurgitation 

Can be used for up to 28 days' treatment 

For adults over 18 (not pregnant or breastfeeding women) 

Long duration of action - one tablet gives up to 24-hour acid suppression, 

providing day and night symptom relief 

Effective - gives complete symptom relief in 70 per cent of sufferers after seven days 4 
Provides sustained relief, but not immediate relief - treatment for 2-3 consecutive 
days may be necessary to improve symptoms 

Well established safety profile. Some 5 per cent of patients may experience ADRs - 
diarrhoea and headache are most common 

The parietal cells in the stomach produce gastric acid, and can secrete up to two litres a day. Proton pumps in the parietal cells 
are responsible for the final step of acid production. Pantoprazole binds irreversibly to proton pumps, thus suppressing acid 
production 'at source'. This raises the pH of the stomach contents and reduces the 
severity of heartburn. 

Normally triggers such as the sight and smell of food lead to 
the activation of proton pumps. Such triggers cause nervous 
and/or hormonal stimuli, leading to production of histamine, 
acetylcholine or gastrin, that 'switch on' proton pumps. 

H2 antagonists reduce acid secretion by blocking histamine 
receptors, and have no effect on other stimuli. They therefore 
inhibit acid production to a lesser extent than PPIs such as 

Antacids neutralise acid in the stomach and have no 
inhibitory effect on acid secretion at all. They only provide short 
term relief from the symptoms of heartburn, rather than tackling 
the cause. 





References: 1. Dent J, El-Serag HB et al. Gut 2005; 54: 710-71 7 2. Shaker R, Castell DO et al. Am J Gastroenterol 2003; 98: 1487-1493 3. NICE Clinical Guideline no 17. Dyspepsia - management of 
dyspepsia in adults in primary care 4. EMEA. Assessment report for Pantoloc Control 2009. Doc ref EMEA/374696/2009 
Pantoloc Control® 20mg gastro-resistant tablets 

Presentation: Yellow tablets containing 20mg pantoprazole (as sodium sesquihydrate). Indications: Short term treatment of reflux symptoms (e.g. heartburn, acid regurgitation) in adults. Dosage and 
Administration: Adults (including elderly) one tablet daily. Children under 1 8 years: not recommended. Treatment may be necessary for 2 to 3 consecutive days to achieve symptom improvement. If no 
symptom relief within 2 weeks consult a doctor. Treatment should not exceed 4 weeks without consulting doctor. Contraindications: Hypersensitivity to active, to soya or any of excipients. Co-administration 
with atazanavir. Precautions: patients should consult doctor in cases of: unintentional weight loss, anaemia, Gl bleeding, dysphagia, persistent vomiting, vomiting with blood, previous Gl ulcer or Gl surgery, 
symptomatic treatment more than 4 weeks, jaundice, hepatic impairment, liver disease, over 55 years, recently changed symptoms, serious disease affecting general well-being. Interactions: possible reduced 
absorption of actives whose bioavailability is pH dependent (eg ketoconazole); reduced bioavailability of atazanavir. As pantoprazole is metabolised by cytochrome P450 enzyme systems possible interactions 
with substances metabolised by same enzyme system cannot be excluded Pregnancy & Lactation: not recommended. Side Effects: Uncommon: headache; dizziness; diarrhoea; nausea/vomiting; abdominal 
distension, bloating, pain and discomfort; constipation; dry mouth; rash, exanthema, eruption; pruritus; asthenia, fatigue and malaise; sleep disorders; raised liver enzymes. Rare; disturbances/blurring of vision; 
urticaria; angioedema; arthralgia; myalgia; hyperlipidaemias and lipid increases; weight changes; raised body temperature; peripheral oedema; hypersensitivity reactions; bilirubin increased; depression. Very 
rare: thrombocytopenia; leucopenia; disorientation. Frequency not known: interstitial nephritis; Stevens-Johnson syndrome; Lyell syndrome; erythema multiforme; photosensitivity; hyponatraemia; jaundice; 
hepatocellular injury/failure; hallucination, confusion. Legal Category: P. RRP: 7 tablets: £6.90; 14 tablets: £11.90 Marketing Authorisation No: EU/1/09/519/001-004 MA Holder: Nycomed GmbH, Byk- 
Gulden-Str.2, D-78467 Konstanz, Germany. Date of Preparation: February 201 0. Further information is available from Novartis Consumer Health, Wimblehurst Road, Horsham, RH1 2 5AB, UK. 
Please refer to SPC for full prescribing information. 




19 Pregnancy 


25 Budget ► 26 Methadone ► 28 Cat M ► 30 Team morale 

f 32 LPCs 

The Budget 2010 deciphere 

The good, the bad and the ugly - finance expert Paulo Tallon explains how the 
chancellor's emergency deficit reduction measures will affect you 

1. The proposal Increase VAT standard rate to 20 
per cent. 

Why it's not as bad as it might have been: 

• The increase is deferred until January 2011. 
i The problems some businesses experienced 
with a January 1 change date were acknowledged 
with a proposed effective date of January 4. 

There is no increase in the 5 per cent rate of 
VAT, and no extension of VAT to any goods or 
services that are currently exempt or zero-rated. 

2. The proposal Reduced annual writing down 
allowances for capital expenditure - from 20 to 18 
per cent for the main rate, and from 10 to 8 per 
cent for certain types of asset including some cars 
and integral features in buildings. 
Why it's not as bad as it might have been: 

• The reductions are not as great as some had 
feared, and the change is deferred for two years. 

3. The proposal Increase in the rate of capital 
gains tax to 28 per cent for disposals by higher 
rate taxpayers after June 22, 2010. 

Why it's not as bad as it might have been: 

• The new rate is not as high as some had feared. 
© The large increase in the entrepreneurs' relief 
lifetime limit from £2 million to £5m will benefit 
many business owners. 

4. The proposal New bank levy from January 2011. 

'hy it's not as bad as it might have been: 

• The expected annual yield of around £2.5 billion 
is relatively low for the sector as a whole. 

1. Corporation tax 

The phased reduction, starting in April 2011, in the 
corporation tax main rate from 28 to 24 per cent, 
and the smaller reduction in the small companies 
rate to 20 per cent, will help to reduce the 
movement of businesses away from the UK and 
attract inward investment, as well as encouraging 
domestic growth. However, this is partly funded 
by the reduction in capital allowances writing 
down rates from April 2012, which will affect 
some businesses more than others. 

2. National insurance 

On the national insurance front, the increase in 
the employer's weekly threshold from £110 to 
£131 from April 2011, and the three-year 
exemption worth up to £5,000 per employee for 
new businesses (broadly) outside the south east 
taking on up to 10 new employees, will help 
companies to retain and recruit staff. 

3. Environmental incentive 

There is an introduction of a 100 per cent first 

Chancellor George Osborne: "an unavoidable Budget" 

year allowance for new zero-emission goods 
vehicles purchased between April 2010 and 
March 2015 

1. Exempt and partially-exempt businesses, 

for whom the VAT increase will be a real cost. 
Retailers will also once again have to go through 
the expensive administrative process of changing 
prices, and may face reduced demand from 
customers if they pass on the full increase. 

2. Businesses that currently claim the full 
£100,000 Annual Investment Allowance, 

which will be reduced to only £25,000 from April 
2012 This will be very disappointing for smaller 
and medium-sized businesses with high capital 
expenditure, especially as the limit was doubled 
from £50,000 to £100,000 only two months 
ago. In the short term, the key here will be to 
utilise the £100,000 allowance as fully as possible 
before it is reduced, which may mean accelerating 
some expenditure. 

For individuals 

1. Income tax 

The £1,000 increase in the personal allowance will 
benefit basic rate taxpayers and take some 
individuals out of the income tax net. 

The announcement that an alternative method 
of restricting pensions tax relief for high earners is 
welcome, as the system that is due to take effect 
in April 2011 would be an administrative 
nightmare for advisers, employers and employees. 
The proposed reduction in the annual allowance 
would be a much simpler way of effecting the 
restriction, and this may be acceptable provided 
that it results in a comparable restriction of relief 
for those affected 

The proposed removal of the requirement to 
buy an annuity at no later than age 75 will also 
provide more flexibility for retired individuals. 

2. Capital gains tax 

The retention of the 18 per cent capital gains tax 
rate for basic rate taxpayers, and the retention of 
the current annual allowance of £10,100, will be 
welcomed by small investors. 

The large increase in the entrepreneurs' relief 
lifetime limit from £2m to £5m will be welcomed 
by those who decided not to realise a gain of up to 
that amount in advance of the Budget. 

Disappointingly, there is no indication so far of a 
change to the rules to enable employees with 
shareholdings of less than 5 per cent in their 
company to benefit from entrepreneurs' relief. 
Many such employees will see the applicable 
capital gains tax rate on the disposal of their 
shares rise from 18 per cent to the new 28 per 
cent. This is still an attractive rate compared to an 
income tax rate of 40 or 50 per cent, but some 
employers will need to re-assess equity reward 

...and finally 

Tax s i m plificati on 

The new government has made a commitment to 
simplify tax legislation and to create more 
stability in the tax system by making fewer 
piecemeal changes. This has so far included the 
promise of an independent Office of Tax 
Simplification, and the proposal to change the 
very complex system for restricting pensions tax 
relief for high earners that is due to take effect 
next April. 

The government has also stated that it will 
review small business tax, in particular the 
unpopular IR35 rules. 

However, simplification may come at a price - 
the government is to consider the introduction of 
a 'general anti-avoidance rule'. This could have 
wide reaching implications for all types of tax 
planning, rather than just the specific areas that 
are currently targeted. 

Paula Tallon, partner, accountancy firm BDO 

CPD Reflect • Plan • Act • Evalu 

Tips for your CPD entry on finance 

REFLECT How will the Budget affect my 

PLAN Review the new tax and benefit 
changes in the Budget. 

ACT Factor the changes into my 

pharmacy business plan. 

EVALUATE Is my pharmacy able tc 
with the Budget? 

26.06.10 Chemist+Druggist 25 


'! 19 Pregnancy 25 Budget s 26 Methadone f 28 Cat M I 30 Team morale !> 32 LPCs 

This series aims to help you make the right decisions when confronted by an ethical dilemma. Every month we present a scenario likely to arise in a 
community pharmacy and ask a practising pharmacist and/or a member of the Pharmacy Law and Ethics Association (PLEA) to comment on the legal and 
ethical implications of the actions open to you. Readers are invited to have their say at 

Advance supply for addicts 

ion I 

Both patients are regular clients and well known 
to your staff. If you did not issue Mr X with Miss 
Y's methadone, one of them would not have their 
weekend doses. You believed Miss Y (or Mr X, if he 
shared his doses) would use another substance if 
she did not receive her dose. By not supplying 
methadone, you could put the patients at risk of 
crime, ill-health and substance misuse, for which 
they have been treated and are recovering well. 

Mr X could be collecting Miss Y's methadone 
without her knowledge and abusing the doses 
himself. Without Miss Y's authority, you would be 
putting yourself up for blame if there was an 
overdose or abuse by Mr X. There could be reprisals 
from Miss Y, the local drug and alcohol clinic and 
doctors looking after both clients. Ethically, it would 
not be appropriate to dispense methadone for a 
patient who is not contactable, and you should 
certainly not allow a known addict to act as a 
courier. Guidelines state patients should collect 
the methadone in person. Representatives may 
collect with an authorising letter. 

Treatment goals under the Clinical Guidelines (the 

CPD Reflect • Plan • Act • Evaluate 

'Orange Book') are to reduce ill-health, crime and 
other problems relating to drug abuse as well as 
to secure abstinence from the main problem drugs. 
Assessing risk is important for pharmacists as part 
of the professional substance misuse team. 

After about three days of regular methadone, a 
patient may lose tolerance and be at risk of 
overdose when the next dose is taken, so it is 
crucial the patient is not without prescribed 
methadone for too long. 

The legislation states that the pharmacist must 
ascertain that the person collecting is the patient's 
representative. Identification is not necessary if 
the patient is known to the pharmacist, but 
authorisation letters are necessary to allow 
people to carry CDs not intended for them. As the 
prescription was already signed by Miss Y when 
first presented, further signatures are not required. 
The Orange Book clarifies that the pharmacist has 
discretion to supply in special circumstances. 

Considering the risks of not providing the 
methadone, I chose to supply it. These were 
exceptional circumstances and I used my own 
professional discretion. 
Lila Thakerar MRPharmS is proprietor of 
Shaftesbury Pharmacy, Harrow 

While it may not be unlawful for a "supervised 
consumption" supply to be made to a patient's 
representative, guidance from the RPSGB states 
that such supplies must be made only with prior 
written authorisation from the patient. 

The pharmacist must not succumb to pressure 
from anyone to supply unless he or she is satisfied 
it is lawful and ethical to do so. The Society and 
judges view pharmacists as trusted custodians of 
potentially harmful medicines; any evidence the 
pharmacist's judgement was swayed by an 
'irritated' patient or carer will not be well received. 

In this scenario, the pharmacist should consider 
whether every possible option for obtaining the 
patient's consent has been explored. For example 
- does the patient live far away? If not, can the 

representative go to the patient's home and ask 
the patient to write a letter of consent or call the 
pharmacist? Can the delivery driver take the supply 
later if the patient is ill? If a supply is refused, is 
the patient likely to come to the pharmacy (or call 
the pharmacy) when the representative gets 
home without the methadone? 

Experience of enforcement action taken by the 
police and the Society suggests that there is 
significantly less room for the exercise of 
professional judgement where the supply of 
schedule 2 Controlled Drugs is concerned. The 
pharmacist should record his or her decision, with 
full reasons, in the patient's PMR. 
Noel Wardle is a solicitor at Charles Russell 
LLP, specialists in pharmacy law 

More dilemmas are online at www.chemist 


PLEA is an association of 
pharmacists interested in 
law and ethics, and lawyers 
or ethicists specialising in 
pharmacy, with the aim of promoting 
understanding of the ethical basis for 
professional judgement 

s Ethical Dilemma; 
ly MST on an undated 
minal cancer? 

thical Dilemmas. If you have 
enario that you can share 
' pharmacists, get in touch 

26Chemist+Dnjggist. 26.06.10 


(excl Private Label) 

Cf)f fiDf V ZT 

<^ cumin' 

For short term treatment of acute moderate pain 
not relieved by paracetamol, ibuprofen or aspirin 

Can cause addiction. Use for 3 days only. 

J roduct Information: Solpadeine Max Soluble Tablets. Presentation: Paracetamol 500 mg, Codeine Phosphate Hemihydrate 12.8 mg and Caffeine 30 mg. Uses: Short term treatment 
if acute moderate pain not relieved by paracetamol, ibuprofen or aspirin alone. Dosage and administration: Dissolve in water before taking. Adults and children, 12 years and over: Two 
ablets up to four times daily. Not more than 8 tablets in 24 hours. Children under 12 years: Not recommended. Do not take for more than 3 days without consulting a doctor. 
Contraindications: Known hypersensitivity to ingredients. Precautions: Can cause addiction. Use for 3 days only. Renal or hepatic impairment, non-cirrhotic alcoholic liver disease. Salt 
estricted diet. Sufferers from persistent headache and withdrawal symptoms should consult a doctor. Interactions: Warfarin or other coumarin anticoagulants, domperidone, metoclopramide, 
alestyramine, monoamine-oxidase inhibitors, mexiletene. Pregnancy/lactation: Do not use without medical advice. Side effects: Paracetamol: rarely, hypersensitivity including skin rash; 
'ery rarely, reports of blood dyscrasias (not necessarily causally related). Codeine: constipation, nausea, vomiting, vertigo, difficulty with micturation, dry mouth, rashes, urticaria, dizziness, 
Irowsiness, restlessness and irritability. Legal category: P. Product licence number: 00071/0234. Product licence holder: GlaxoSmithKline Consumer Healthcare, Brentford, TW3 9GS, 
U.K. Package quantity and RSP: 16s £3.49, 32s £5.89. Date of last revision: January 2010. Solpadeine is a registered trade mark of the GlaxoSmithKline group of companies. 

Source: Neilsen: Total Chemists MAT Value & Unit Sales (11.12.09) 



•J 19 Pregnancy 

25 Budget ■% 26 Methadone 

28 Cat M 

30 Team morale 


32 LPCs 

Category M Barometer 

Generic Eric reveals how July's category M adjustment will affect your business 

or the second quarter in a row, the 
category M tariff has seen an increase in 
overall reimbursement. This quarter's 
addition is in the region of between £15-£17 
million a quarter, once market growth is 
factored in, and will boost the average 
pharmacy's generic purchase profits by £1,203 
over the next three months. 

Again for the second quarter in a row, there has 
been a lot of activity in the category, with only 
seven products out of 443 staying at the same 
reimbursement level as last quarter. However, in 
this quarter more products were reduced (309) 
than increased (127). 

The latest adjustment also sees the removal 
from the tariff of a further two products: 
chloramphenicol eye ointment and diltiazem 
hydrochloride. Most of the savings in the 
£1.7 billion basket have been made to the brand 
new additions to the tariff, of which there are 12. 
The most prominent change is the addition of all 
the losartans, which it is estimated will save the 
NHS £64m a year overall. 

The Category M Barometer index has 
increased from 116.8 in quarter two to 125.9 in 
quarter three. 

On the most commonly dispensed lines by 
volume, reimbursement prices have increased on 
the majority of lines this quarter. Once again, this 
follows the pattern of last quarter's changes, 
though the annualised addition to these lines is, at 
£39m, higher than in quarter two (£33m). For the 
average pharmacy, this equates to £776 being 
added to the bottom line each month (if whole 
market volumes are used and just the top 20 lines 
are dispensed). 

.......... . 

£15-1 7m added this quarter 

What's hot 


The 10 products with the largest rise in price 


price (£) 

price (£) 


Glyceryl trinitrate 500mcg sublingual tablets 







Allopurinol 100mg tablets 







Topiramate 25mg tablets 







Co-cyprindiol 2,000mcg/35mcg tablets 







Allopurinol 300mg tablets 







Gabapentin 300mg capsules 







Oxybutynin 5mg tablets 







Glibenclamide 5mg tablets 







Ranitidine 150mg tablets 







Omeprazole 20mg gastro-resistant capsules 










The 10 products with the largest fall in price 


price (£) 

price (£) 

Losartan 25mg tablets 






Losartan 100mg tablets 






Losartan 50mg tablets 






Losartan/hydrochlorothiazide 50/12. 5mg 






Losartan/hydrochlorothiazide 200/25mg 






Clopidogrel 75mg tablets 






Sodium bicarbonate 500mg capsules 






Clindamycin 150mg capsules 






Ropinirole 500mcg tablets 






Naproxen 500mg gastro-resistant tablets 







and analy 

;is supplied by 


CPD Reflect • Plan • Act • Evaluate 

REFLECT Do I undei 
affects bu 

PLAN Read this. 

the latest 

ACT Change pi 

protect pr 

EVALUATE Ismybusi 
with categ 

28 ( hemist Druggist 26.06.10 

Weight loss benefits 
beyond what the 
eye can see 

alii is the only non-prescription 
weight loss medicine licensed 
throughout Europe A new 
three-month study* has shown 
that alii, when used with a 
reduced calorie, lower-fat diet, 
not only significantly reduces 
total bodyweight but also 
harmful excess visceral fat 1 
that can contribute to diabetes 
and heart disease." 

Help customers understand the 
meaning of healthy weight loss. 
Talk to them about visceral fat 
and positive change with alii. 


alii is for overweight adults with BMI > 28 kg/m 2 

Open-label 3-month study in 24 individuals with BMI > 28 kg/m 2 
and increased waist circumference. Visceral fat measured at 
baseline and endpoint. 

60 mg hard capsules 

Positive change from 
the inside out 

Product Information, alii 60 mg hard capsules (orlistat). 
Indication Weight loss in adults BMI > 28 Dosage Adults 
(18 or over): One capsule within an hour of each of three 
|Sf main meals. Max 3 caps/day for up to 6 months. Use with 

lower fat mildly hypocaloric diet. If no weight loss within 
' '~Nvl. 12 weeks refer to H< -' P Diet anc ' exerci se should start prior to 

treatment Contraindications Hypersensitivity to ingredients; concurrent 
treatment with oral anticoagulants or ciclosporin; chronic malabsorption syndrome, cholestasis, 
pregnancy, breast-feeding. Special warnings and precautions See GP if kidney disease, on 
amiodarone. levothyroxine or medication for diabetes or epilepsy. See HCP if on medication for 
hypertension or hypercholesterolemia Risk of Gl symptoms increases with fat consumption 
-Take multivitamin at bedtime See GP if rectal bleeding. Oral contraceptive efficacy may be 
reduced if severe diarrhoea, use additional contraception. Drug interactions Ciclosporin. oral 

anticoagulants, levothyroxine, antiepileptics, fat soluble vitamins, acarbose, amiodarone Pregnancy 
and lactation. Do not use during pregnancy or lactation Side effects See SPC for full details 
Predominantly gastrointestinal e.g. oily stools, urgency, usually mild arid transient, risk reduced 
by low fat consumption Pancreatitis, oxalate nephropathy, hepatitis, cholelithiasis, abnormal liver 
enzymes, anxiety, hypersensitivity reactions including anaphylaxis, bronchospasm, angioedema, 
pruritus, rash, arid urticaria; bullous eruption Legal category f Marketing Authorisation 
Holder Glaxo Group Limited. Greenford, Middlesex. UB6 ONN MA Number EU/1/07/401/007 009 
& Oil Pack size and RSP (excl. VAT) 42s £2865, 84s £4343. 120;, £5102 Last revised April 2010 
References 1 GSI data on file 2010 (visceral fat 
study 1) 2 World HealthOrganisation.Thechallenge 
of obesity in the WHO European region and the 
strategies for response 2007 Available at wwweuro. Accessed 14/1/10 


alii is a registered trademark of the GlaxoSmithKiine group of cornpanie 


4 19 Pregnancy 4 25 Budget ^26 Methadone 4 28 Cat M 30 Team morale ► 32 LPCs 

Health and wellbeing at work is important for both employees and pharmacy businesses - without healthy happy staff, customer service is likely to 
suffer. Over the coming months C+D will be giving you guides and tips on improving your wellbeing, covering everything from boosting morale in the 
dispensary to your legal rights. If there is a health and wellbeing issue you would like us to cover, 


ways to make your 
pharmacy a happier place 

Even little steps can help raise morale in your pharmacy, finds Zoe Smeaton 

It's one of the oldest tricks in the book, but saying 
thank you really can make all the difference to 
someone's day. Janice Perkins, superintendent 
pharmacist at the Co-operative Pharmacy, says: 
"Passing on compliments and giving good feedback 
is extremely important." As a start, find specific 
things people have done well and thank them. As 
Kathryn Featherstone, Listening Friend co- 
ordinator at charity Pharmacist Support, says: 
"My top tip would be to remember to praise staff 
regularly and offer congratulations for jobs well 
done - for little things like finishing the cleaning 
for the week early or more important things like 
picking up a dispensing error before it goes out." 

Neal Patel, RPSCB head of corporate 
communications, says it's vital to make sure your 
team have opportunities for training so they can 
develop their skills and feel they have a real 
contribution to make. And Sanjay Pathak, head of 
professional services at Alliance Healthcare, 
agrees. "Boredom is a major factor to loss of 
motivation and downturn in performance," he 
warns. To combat it and make staff happier he 
suggests it is important to have a development 
plan for each member of your team. Mr Pathak 
says: "The development plan should help you 
strengthen the skill mix and potential of your 
team. Ensure that you keep your promises and if 
this is not possible suggest an alternative." 

Boots pharmacist Angela Chalmers says making 
your team feel valued as people not just numbers 
is important for any happy pharmacy. So try to be 
aware of people's personal lives, looking for signs 
they might be a bit down or stressed and chatting 
to them about it if needed. Mr Pathak suggests the 
simple step of recognising life events such as births 
and marriages with cards, presents or in other ways. 

Communicating with your team is a vital step to 
improving their work contentment, experts agree. 
Ms Chalmers suggests a weekly briefing to let 
them know what is going well, what not so well, 

Simple gestures such as making staff a hot drink can 
have a big impact on morale 

and to get their opinion on how to make things 
better. And Mr Pathak says it is vital to share goals 
with your team and involve them in new 
initiatives, and also stresses the need to take their 
feedback on board, possibly by having a staff 
forum for feedback or even a staff survey. 

Biscuits, a fresh brew or home baking really can 
make a difference. As Ms Featherstone says: "Cake 
can go a long way to improving a long afternoon!" 
Alastair Buxton, head of NHS services at PSNC, 
says: "I used to ensure there was a freshly brewed 
pot of coffee waiting when my team arrived just 
before 9am. It kick started the day very effectively." 

"As an employer, you may want to have financial 
incentives in place for employees who have not 
had any absences and bonus schemes linked to 
the performance of the individual and the 
organisations with very clear key performance 
indicators," Mr Pathak suggests. 

Getting out and about can be a great way to 
improve relationships within your team. Diane 
Leicester, charity manager at Pharmacist Support, 
says enjoying time together away from the office 
can help people feel better about work. And Ms 
Chalmers advises: "Arrange something fun out of 
work now and again; it's great for catching up and 
having a laugh. Keep the activity simple and 
inexpensive so it is inclusive and affordable for all." 

Working environment can have a huge impact on 
team morale. Mr Pathak warns that simple factors 
such as lighting and heating can make a huge 
difference to moods and how people feel. "You 
may have to consider or revisit processes and 
layout to enable you to support your team," he 
says. And Hiten Patel, director of Pharma Plus, 
adds: "Shops need adequate lighting; you see 
some and you don't know whether the shop is 
open or closed, and I don't like to think what the 
mood would be like inside." 

- /tfOfiCI 

Sharing workload is key to making everyone feel 
they are working equally hard and avoid one 
person feeling hard done by, as Ms Leicester 
suggests: "Take turns with known 'difficult' 
customers that regularly visit the pharmacy, so 
that one person is not left to serve them week in, 
week out." 

Another old message that still needs repeating. It 
can be tempting to work through the day without 
a rest when you have targets to meet and 
customers to deal with, but if at all possible Ms 
Leicester advises encouraging your team to take a 
break for lunch or just a coffee to help improve 
their working day. 

CPD Reflect • Plan • Act • Evaluate 

Tips for your CPD entry on team morale 



Can I make my pharmacy a 
happier place to work in and so 
improve staff performance? 

Identify potential ways to boost 
staff morale 


Implement these and listen to 
staff feedback 

EVALUATE Have new measures made 
staff happier and boosted 

30 Chemist+Druggist 26.06.10 


19 Pregnancy \ 25 Budget : < 26 Methadone ! 28 Cat M i 30 Team morale W 32 LPCs 


Reasons to join your LPC 

Zoe Smeaton hears how getting involved in your LPC can improve your own credentials 

The idea of giving up your 
evenings to pore over the 
latest pharmacy service 
specifications may not be the most 
appealing idea. But local 
pharmaceutical committees 
(LPCs) have moved on and getting 
involved might be more fun, and 
better for your career prospects, 
than you imagine. 

LPCs are the local leadership 
bodies for community pharmacy. 
Meetings are likely to cover 
everything from pharmacist worries 
or service delivery to how the 
profession can best negotiate with 
commissioners or get doctors on 
their side. Being on the committee 
therefore requires a passion for the 
profession and determination to 
help it develop. There are also key 
skills you'll be able to develop and 
put into practice. 

Salim Jetha, CEO at Avicenna, 
says: "Working as a team would help 
develop your communication skills. 
You will have the opportunity to 
share opinions and raise issues and 
will be accountable and questionable 
by the contractors at large." 

Mike King, head of LPC and 
contractor support at PSNC, says it 
offers training to LPCs on a regular 
basis, which you could take 
advantage of. 

As well as covering specific 
politically important topics that 
would help improve your knowledge 
of the sector, these also touch on 
topics such as leadership, 
negotiations and management. 
These are all transferable skills likely 
to help you in other areas of your 
working life, too - perhaps you'll be 
better placed to manage your own 

LPC meetings are a great way to network and learn from other pharmacists 

"Being on your 
LPC shows you 
have initiative" 

team or negotiate that all-important 
pay rise. 

Just attending meetings and mixing 
with other pharmacists also brings 
benefits, as Boots pharmacist Angela 
Chalmers says: "You will get to work 
in a different capacity with a team of 
pharmacists passionate about 
community pharmacy. You will meet 
a number of other pharmacists 
working in other areas of pharmacy 
- so it's great for networking." 

On top of all of this, being part of 
your LPC will give you an insight into 
what is happening with pharmacy 
services locally. This could be useful 
and make you attractive to 
employers, as Mr Jetha notes: "The 
employer will benefit if you 
demonstrate that you have a better 
understanding of the issues facing 
the sector." Mimi Lau, Numark's 

CPD Reflect • Plan • Act • Evaluate 

Tips for your CPD entry on pharmacy policy 

REFLECT Could joining my LPC help improve my understanding of 
the sector and its future? 

PLAN Find out about my LPC and who to speak to in my company 
about joining it 

ACT Speak to employer or the LPC about getting involved and 

then attend LPC meetings 

EVALUATE Has being involved in the LPC improved my practice and 
knowledge of pharmacy? 

director of professional and training 
services, agrees: "The benefit of 
doing this is great from a business 
perspective in that it gives you a 
'heads up' on what is happening 
locally with regards to PCT priorities 
and new service commissioning 

Having experience working at a 
strategic level in this way is likely to 
help if you're looking to progress 
from pharmacist to area manager, 
for example. Being on your LPC also 
demonstrates your enthusiasm for 
the sector, and shows you have 
initiative and are prepared to take on 
new challenges. It could even act as 
a stepping stone to a position on 
PSNC or other pharmacy bodies. 

If you're concerned about the 
time commitment, speak to your 
LPC. Nowadays many hold their 
meetings in the daytime, so you 
shouldn't even have to put in hours 
after work as long as your employer 
is happy to provide cover for you 
being out of the dispensary. 

Suzanne Austin, service 
development pharmacist at the Co- 
operative Pharmacy and executive 
secretary of South Cheshire LPC, 
says her company provides cover for 
pharmacists to attend the meetings, 
and at the end of the year 
pharmacists receive a payment for 
sitting on the committee. Your travel 
expenses will be met by the LPC. 

So if you're keen to start climbing 
that career ladder, give some 
thought to joining your LPC. As Ms 
Lau concludes, it may require some 
effort on your part, but "the reward 
is potentially high". 

Tips for joining 

LPCs hold elections every four 
years and standing for election is 
a key route to getting a position 
on the committee. You will need 
to find people to nominate you if 
you want to stand for election - 
your LPC will have all the details 
on these and your employer 
should be able to help you 
complete the application. 

If you work for a CCA company 
there is likely to be someone 
within the organisation 
responsible for LPC support -you 
can ask your manager who that 
person is and then contact them, 
telling them you would be 
interested in sitting on an LPC. 
Co-operative Pharmacy service 
development pharmacist 
Suzanne Austin says the CCA 
itself could also point you in the 
right direction. 

If you work for an independent 
you might be better off 
contacting the LPC directly. CCA 
members can consider this, too - 
it's worth speaking to the LPC 
secretary and letting them know 
you would be interested if 
vacancies came up on the 
committee. You can find LPC 
contact details via the PSNC 
website, and experts agree the 
main thing you're going to need 
is enthusiasm, so just picking up 
the phone or sending an email to 
show interest is likely to put you 
in a good position to be 

If you're nervous about your 
first LPC meeting, PSNC's Mike 
King suggests calling the 
chairman beforehand to find out 
more about what will be 
discussed. Try meeting someone 
else from the committee before 
and then going along with them. 

Ms Austin also says it is normal 
not to understand everything so 
don't be afraid to ask. As long as 
you make an effort to read any 
papers beforehand and show an 
interest, fellow committee 
members will be happy. 

32 Chemist :-Druggist 26.06.10 


C+D Jobs celebrates 7,094 unique monthly users 

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34 Chemist+Druggist 26.06.10 

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Let employers come to you - publish a CV 



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ho's got relationship issues? 

Postscript was rummaging around the usual 
mess that festers on its desk last week, when 
it stumbled across a book next to a half- 
eaten Ploughman's and a BNF from March 
2003: Sick Notes, by DrTony Copperfield. 

The book is a hilarious sideways glance 
at medical practice on the frontline, 
through the eyes of the Times' 
pseudonymed CP. Patients, practice 
and practitioners - nothing 
escapes Copperfield's acerbic wit 
and snarky humour, painting a 
pretty recognisable portrait of 
primary care. 

However, Postscript did take 
exception to Copperfield's 
cheeky pop at pharmacists 
throughout the pages. So much so that 
Postscript caught up with him (pseudonymed 
characters all meet together at bi-monthly 
cocktail parties), and asked what he had to say for 
himself. Here's Copperfield's reply: 

"Despite what the book says, I quite like 
pharmacists. Partly because we're all supposed to 
be part of one big primary care family, running 
hand in hand in soft focus through fields of corn in 
a concerted effort to save our patients from viral-, 
pollen- or emotional-induced sniffles. But also 
because you do very occasionally bale me out ('Dr 


Copperfield, can I just check you really did want 
to prescribe some potentially bone- 
marrow-toxic chloramphenicol 
capsules for this child's 
conjunctivitis? Or 
would you rather I 
dispense the ointment?') 
And you do it without 
laughing at me. 
"You know there's a but 
coming, though. And it's this. 
But I do wonder whether 
you've ever resolved that 
tension between being a health 
professional and being a 
shopkeeper. Because while your 
shelves are filled with vitamins, 
tonics and herbal rubbish, I find it 
hard to take seriously all the good 
work you do. It's as though you're doing 
a customer's cardiovascular risk prediction on the 
one hand and, on the other, telling him his fortune. 
Get over your identity crisis and I'll view you in a 
much more sympathetic light. Though I'll have far 
less to write about." 

So here's the deal. Postscript will give away its 
copy of Sick Notes to the pharmacist who comes 
up with the best riposte to the good doctor - the 
rest of you will just have to buy it. Send your 
responses to 
by July 10. The winner will get the book, and their 
comment passed on to Dr Copperfield. 

C+D reader of the week 

Meet Kha[id Ahmed of Asda pharmacy in Manchester, and find out 
who this superstar DJ would pick to play him in a movie 

If you could offer amy new service, what would 

it be? Hepatitis C testing. There is a very large 
population in the UK that's undiagnosed. 

Who's going to win the World Cup? After their 
performance against North Korea, I'd say Portugal. 

What's the worst thing about being a 
pharmacist? Sticking labels on boxes. Or just 
having your head stuck in prescriptions, not talking 
to people. 

Do your relatives ask you for medical advice? 

All the time. They ask about anything from head 
lice to what they should take for malaria. I'm like a 
doctor on call, there to provide advice even if my 
eyes are closed. 

What's your claim to fame? Being the number 
one DJ in Manchester. I've performed at 

Manchester Mega Mela, in Preston, in Rochdale, 
and played alongside the Asian Robbie Williams. 
And I DJed at Blackburn Rovers' ground last night. 

Who's the unsung hero in your pharmacy? 

John Evans, our superintendent pharmacist. He 
does a lot of work in the background. 

If someone made a film about you, who would 
be cast as you? Shahrukh Khan [Bollywood 
movie star]. 

What should we ask the next interviewee? If 

you could choose any career other than pharmacy, 
what would you pick? 

Calling all pharmacists and technicians. We 
want you to be our reader of the week. Email 
us at 

Got a story for Postscript? 

1 4 

• .■== — ■ 

@>The web hunter 

Last week I was happily watching traffic to C+D 
soar on the back of our new email strategy and 
was just in the process of giving myself a pat on 
the back when the whistle blew for the start of the 
World Cup. 

It's a funny old game running a website and 
even more so with the World Cup on. Like football, 
the web is all about statistics. Page views, unique 
visitors, click through rates -you name it, we've 
got it. The only thing we are lacking is red cards. 

Now I know a few things about retail, including 
how major sporting events are a double-edged 
sword. Before the tournament everyone is buying 
England merchandise and it's happy days. But the 
moment the whistle blows, everyone is indoors 
watching the TV and supping on beer they have 
undoubtedly bought in some sort of two-for one 
deal from their local supermarket. 

So last week, as the tournament began, traffic 
to our site plummeted to its 2009 levels and 
response rates to our emails went through the 
floor. And, unsurprisingly, retailers bemoaned that 
everyone was at home rather than shopping. 

And, like Fabio Capello does when England 
underperforms, I have to explain to the head of 
the FA (or in my case, my editor), why. 

So what's the solution? Well Fabio dropped 
Green in favour of 'calamity' James. Multiples 
have found more inventive ways of selling England 
merchandise (even if they are not allowed to 
adorn their delivery vans and offices). And we are 
trying to mention football and the World Cup in 
more of our web articles. 

But the lesson for me is stats. You can watch 
trends and make educated forecasts about 
performance but, as in football, you can never 
truly predict the outcome. 
Niall Hunt is C+D's digital content editor; 
email him at 

A social tweet 

C+D ran a competition to find the best uses 
for a vuvuzela last week. Here are the pick of 
the responses that we could print. Join the 
debate at 

@CandDChris: Top 10 uses for a vuvuzela: no.1: a 
replacement peg-leg for a pirate. 

@Finchfancies: Hopi ear-candling for elephants? 

@Squeelaa: Number 8 As a toad tunnel under a 
small footpath. 

38 Chemist- Druggist 26.06.10 



Coming soon 

A training course from 
C+D in association with 
NHS Northwest Medicines 
Management Network 

Medicines Management in Care Homes 
is a training resource pack, providing the 
knowledge, information and tools required 
for you to plan and deliver basic medicines 
management training to staff working within 
care homes. 

The training resource pack consists of: 
Tutor manual 
Presentation aid 

Access to online resources and updates 
Student workbook 

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When neuropathic pain makes 

diabetes hard to bear 


Fast onset. Sustained relief. 

O Proven clinical efficacy in neuropathic pain 1 4 

O Rapid 2 - 4 and sustained relief in patients with painful 
diabetic peripheral neuropathy 245 

O Well-tolerated with a predictable pharmacokinetic profile 6 

Lyrica '(pregabalin) Prescribing Information 
Refer to Summary of Product Characteristics (SmPC) before 
prescribing. Presentation: Lyrica is supplied in hard capsules 
containing 25mg, 50mg, 75mg, lOOmg, 150mg, 200mg or 300mg 
of pregabalm Indications: Treatment of peripheral and central 
neuropathic pain in adults Dosage: Adults 150 to 600mg per day 
in either two or three divided doses taken orally Treatment may be 
initialed at a dose of I50mg per day and, based oo individual patient 
response and tolerability, may be increased to 300mg per day after an 
interval of 3-7 days, and to a maximum dose of 600mg pel day after an 
additional 7-day interval Treatment should be discontinued gradually 
over a minimum of one week Renal impairment/ Hemodialysis 
dosage adiustment necessary, see SmPC Hepatic impairment 
No dosage adiustment reguirerl Elderly Dosage adjustment 
required if impaired renal function Children and adolescents Not 
recommended Contra-indications: Hypersensitivity to active 
substance or excipients Warnings and precautions: There 
have been reports of hypersensitivity reactions, including cases of 
angioedema Pregabalm should be discontinued immediately if 
symptoms of angioedema. such as facial, perioral, or upper airway 
swelling occur Patients with galactose intolerance, the Lapp lactase 
deficiency or glucose-galactose malabsorption should not take Lyrica 
Some diabetic patients who gam weight may require adiustment to 
hypoglycaemic medication Occurrence of dizziness and somnolence 
could increase accidental injury (fall] in elderly patients There have 
also been post marketing reports of loss of consciousness, confusion 
and mental impairment Cases of renal failure have been reported and 
discontinuation of pregabalm did show leversibility of this adverse 
effect In controlled studies, a higher proportion of patients treated 
with piegabalin reported blurred vision than did patients heated 
with placebo which resolved in a maiority of cases with continued 
dosing In the clinical studies where ophthalmologic testing was 
conducted, the incidence of visual acuity reduction and visual field 
changes was greater in pregabalin-treated patients than in placebo- 
treated patients, the incidence of fundoscopic changes was greater 
in placebo-treated patients In the postmarketing experience, visual 
adverse reactions have also been reported, most of which refer to 
transient vision loss, visual blurring 01 other changes ol visual acuity 
Discontinuation of pregabalm may result in resolution or improvement 
of these visual symptoms Suicidal ideation and behaviour have 

been reported in patients treated with anti-epileptic agents 
A meta-analysis of randomised placebo controlled trials of anti- 
epileptic drugs has also shown a small increased risk of suicidal 
ideation and behaviour The data does not exclude the possibility of an 
increased risk for pregabalin Patients should be monitored for signs 
of suicidal ideation and behaviours and appropriate treatment should 
be considered Patients (and caregivers of patients) should be advised 
to seek medical advice should signs of suicidal ideation or behaviour 
emerge After discontinuation of short and long-term treatment 
withdrawal symptoms have been observed in some patients: insomnia, 
headache, nausea, diarrhoea, flu syndrome, nervousness, depressioo, 
pain, sweating and dizziness The patient should be informed about 
this at the start of the treatment Concerning discontinuation of 
long-term treatment there are no data of the incidence and severity 
of withdrawal symptoms in relation to duration of use and dosage of 
pregabalin (see side effects) There have been post-marketing reports 
ol congestive heart failure in some patients receiving pregabalin 
These were mostly elderly, cardiovascular compromised patients 
who received treatment for a neuropathic indication Pregabalin 
should be used with caution in these patients. Discontinuation 
of pregabalin may resolve the reaction Ability to drive and 
use machines: May affect ability to drive or operate machinery. 
Interactions: Pregabalin appears to be additive in the impairment 
of cognitive and gross motoi function caused by oxycodone and may 
potentiate the effects of ethanol and lorazepam In the postmarketing 
experience, there are reports of respiratory failure and coma in 
patients taking pregabalin and other CNS depressant medications 
Pregnancy and lactation: Lyrica should not be used during 
pregnancy unless benefit outweighs risk Effective contraception 
must be used in women of childbearing potential Breast-feeding 
is not recommended during treatment with Lyrica Side effects: 
Adverse reactions during clinical trials were usually mild to moderate 

Most commonly (>1/10) reported side effects in placebo- 
controlled, double-blind studies were somnolence and dizziness 
Commonly (>1/100, <1/10) reported side effects were appetite 
increased, euphoric mood, confusion, libido decreased, irritability, 
ataxia, disturbance in attention, coordination abnormal, memory 
impairment, tremor, dysarthria, paresthesia, vision blurred, diplopia, 
disorientation, balance disorder, insomnia, vertigo, dry mouth, 
constipation, vomiting, flatulence, erectile dysfunction, fatigue, 
oedema peripheral, feeling drunk, lethargy, sedation, oedema, gait 
abnormal and weight increased See SmPC for less commonly reported 
side effects After discontinuation of short and long-term treatment 
withdrawal symptoms have been observed in some patients, 
insomnia, headache, nausea, diarrhoea, flu syndrome, nervousness, 
depression, pain, sweating and dizziness Concerning discontinuation 
of long-term treatment there are no data of the incidence and severity 
of withdrawal symptoms in relation to duration of use and dosage 
of piegabalin (see warnings and precautions) In the post-marketing 
experience, the most commonly reported adverse events observed 
when pregabalin was taken in overdose included somnolence, 
confusional state, agitation, and restlessness Legal category: POM 
Date of revision: August 2009 Package quantities, marketing 
authorisation numbers and basic NHS price: Lyrica 25mg, 
EU/1/04/279/003, 56 caps. £6440, EU/1/04/279/004, 84 caps: 
£96 60; Lyrica 50mg, EU/t/04/279/009, 84 caps £96 60, Lyrica 75mg, 
EU/1/04/279/012, 56 caps £64 40, Lyrica 100mg, EU/1/04/279/015, 
84 caps £9660, Lyrica 150mg, EU/1/04/279/018, 56 caps £64 40; 
Lyrica 200mg, EU/1/04/279/021, 84 caps' £96.60, Lyrica 300mg, 
EU/1/04/279/024, 56 caps: £6440 Marketing Authorisation 
Holder: Pfizer Limited, Ramsgate Road, Sandwich, Kent, CT13 9NJ, UK 
Lyrica is a registered trade mark Further information is available on 
request from: Medical Information Department, Pfizer Limited, Walton 
Oaks, Dorking Road, Waltoo-on-the-Hill, Surrey KT20 7NS 

Adverse events should be reported. Reporting forms and information can be found at . 
Adverse events should also be reported to Pfizer Medical Information on 01304 616161 

References: 1. Siddall PJ, et al Neurology 2006:67(10)' 1792 
Schmerz 2006,20(4) 285-92 4. Freeman R. et al Diabetes Care 
Summary of Product Characteristics (EMEA) 

LYN 669C ©Pfizer Limited 2010 All rights reserved Date of preparation March 2010 

2. Freynhagen R, et al Pain. 2005. 1 1 5(3) 254-63. 3. Freynhagen R. et al 
31(7)1448-54 5. Stacey BR. et al Pain Med 2008:9(8) 1 202-8. 6. LYRICA"",